ULTRA VISION FAMILY EYE CARE

OPTICAL VISIT NEW INTAKE

Name*

Prefix First Last Suffix

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone*

Please provide email address:*

Yes, I will
No, I decline

Email Address*

I am*

purchasing new frames and lenses
using my own frame and purchasing new lenses
using my own lenses and purchasing new frames

I am*

using an outside prescription

Outside Prescription*

I agree to the office policy regarding outside prescriptions.

I am using an outside prescription. I understand that if I am unable to see with my new lenses, I have to see my prescribing doctor to recheck my vision.

In an effort to accommodate our patients, Ultra Vision OD PA is more than happy to reuse a patient’s own frame. We will use the utmost care when handling the patient’s previously worn frame(s) and/or lenses. However, there are many factors that go into why a frame may break--including quality, age, usage and frame material. Plastic materials can become brittle, and solder points on metal frames can weaken or become corroded over time. Frame defects are not always visible, even by the trained eye. In these cases, the frame may not support new lenses.

Frame manufacturers also regularly discontinue old frame styles as they launch new ones. Your frame may be discontinued, in which case we will not be able to order a replacement frame or obtain parts for repair if your frame breaks.

New frames purchased from other retailers can vary wildly in durability and quality. We can only guarantee the quality and durability of the frames from our optical.

Ultra Vision OD PA and members of the staff are not liable for any claims of damage to frames that have not been purchased at the office, the patient’s own frame, or a frame that is over a year old. Ultra Vision OD PA does not know the durability and life of these frames and therefore will not be held accountable should they break or crack when new lenses are inserted.

If the patient chooses to have us make their new lenses for frames not purchased at the office, the patient’s own frame, or a frame that is over a year old and it breaks during the process, the patient will be responsible for (A) the purchase price of a new eyeglass frame and (B) another set of ophthalmic lenses to be cut and fit into that new frame.

If applicable, I understand that polycarbonate lenses are recommended for safety, however, I decline this option; I release Ultra Vision O.D. P.A. and members of the staff from any liability resulting from using plastic lenses.

Frame-Lens Waiver*

I have read and understand the waiver

Ultra Vision OD PA and members of the staff are not liable for any claims of damage to frames that have not been purchased at the office, the patient’s own frame, or a frame that is over a year old.

Should breakage occur from any of the above frame, the patient is responsible for (A) the purchase price of a new eyeglass frame and (B) another set of ophthalmic lenses to be cut and fit into new frames.

If applicable, the patient releases Ultra Vision OD PA and members of the staff from any liability resulting from using plastic lenses.

CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

Health Information Protection*

I have read and agree to the Privacy Policy

I have received and read the office’s HIPAA policy above. A copy of the policy may be provided upon request.

ALL FEES ARE NON-REFUNDABLE AND MUST BE RENDERED AT TIME OF SERVICE

Patient Financial Responsibility*

I have read and agree to the Financial Policy

I have read the office’s financial policy above. A copy of the policy may be provided upon request. I guarantee payment of all charges incurred for the account of the above patient.

Name*

First Last

Signature*

Date*