Medical History
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We live in a digital world where we are constantly viewing screens, whether it be cell phones,
computers, laptops, tablets, TVs, and so on.
Unfortunately, these devices release "blue light" which are wavelengths that cause eye fatigue, eye
strain, headaches, low energy, and disrupted sleep.
Although we cannot stop using these devices, we can protect our eyes from their unwanted effects.
When using a laptop or computer, do you generally stare at the screen without moving your eyes much
(static), or do you often look away at objects that are closer or farther away (dynamic)?
Do you experience any of the following when using a laptop or computer: neck pain, shoulder/trap pain,
or tilting head upwards to see the computer screen better?
South Florida has excessive amounts of sun exposure and harmful UV rays that can harm our eyes.
Daytime activities such as driving, running errands, outdoor exercise, sunbathing at the beach or
pool, boating, fishing, etc. expose us to these UV rays.
This can lead to early cataract development, pterygiums, ocular skin cancer, cosmetic changes in
skin color, and the appearance or worsening of fine lines around the eyes.
Do you have a pair of sunglasses with polarized lenses?
Are you experiencing any of the following during night-time driving? Blurry street signs, glare, halos
around lights, or reduced contrast?
Do your eyes feel tired at the end of the day?
How satisfied are you with the function & comfort of your current eyewear?
Additional comments:
Ocular History
Do you have any of the following conditions? -
Medical History
Do you have any of the following conditions? -
Office Policies
Acknowledgement and Assumption of Risk
I acknowledge that I have voluntarily chosen to receive optical services at Jade Optical. I understand
that these services involve procedures related to eye care and eyewear prescriptions, which may include
risks such as discomfort, irritation, or other complications that are unforeseen, despite the care and
precautions taken. I assume all risks associated with these services and choose to proceed with the full
understanding of the nature and potential outcomes of the procedures.
Waiver of Liability and Indemnification
In consideration for receiving care from Jade Optical, I agree to the following on behalf of myself, my
heirs, personal representatives, and any other person claiming on my behalf:
a. Waiver of Liability: I release Jade Optical, along with its employees and officers, from all
liability for any harm, personal injury, death, or property damage that occurs to me as a result of
my appointment, to the extent permitted by law. This waiver does not include claims arising from
Jade Optical's intentional misconduct.
b. Indemnification: I agree to defend, indemnify, and hold harmless Jade Optical and its employees
and officers against any claims, damages, losses, liabilities, and expenses related to my
appointment, except for those resulting from Jade Optical's intentional misconduct.
This agreement is intended to be as broad and inclusive as permitted by law. If any portion of this
agreement is held invalid, the remaining terms shall continue in full force and effect.
Confirmation of Understanding and Agreement
I affirm that I am at least 18 years old, or that I am signing this agreement on behalf of a minor
as their legal guardian. I have read this document fully, I understand its terms, and I understand
that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing
this agreement freely and voluntarily.
Read Before Signing
Signature: Date:
Signature (Parent / Guardian): Date:
Retinal Photo Test
Enhance Your Eye Care with Our Digital Retinal Photo Screening
At Jade Optical, we are excited to offer our patients the latest in eye health technology-the Digital
Retinal Photo Screener. This quick and comfortable test captures a detailed image of the inside of your
eye without the need for eye drops or any discomfort.
Why Choose Digital Retinal Photo Screening?
Detect Early Signs of Eye Diseases: Our advanced screener can identify key signs of ocular
conditions, including: Glaucoma, Macular Degeneration, Retinal Detachments, Ocular Cancer, Vascular
issues in the retina, and many other conditions.
Monitor General Health: This screening can also reveal signs of systemic health issues such as:
Diabetes, High Blood Pressure, High Cholesterol, Thyroid Disorders, and others.
Benefits of the Digital Retinal Photo:
Baseline Documentation: Establish a visual record of your eye health, which is crucial for
monitoring changes over time.
Enhanced Accuracy: Allows for a more detailed and accurate examination of the eye, even through
an undilated pupil.
Easy Sharing: Provides digital images that can be easily shared with your primary care doctor or
specialists for coordinated care
Personal Copy Available: Upon request, we can provide you with a digital copy of your retinal
photo for your personal records.
Recommended by Our Doctors:
Our doctor highly recommends this screening for all patients, especially if you are visiting us for the
first time. It's an excellent way to get a comprehensive view of your eye health and contributes
significantly to our ability to care for your eyes with precision.
Affordable and Potentially Reimbursable:
The fee for this essential screening is only $39.00. We provide a receipt which you may use for
insurance reimbursement, depending on your coverage. Our staff will assist you in determining if your
insurance plan covers this service.
Note: While incredibly informative, the Digital Retinal Photo does not replace a dilated eye exam
but is a valuable addition to your regular eye health check-ups.
YES, I do want the Digital Photo Exam NO, I do not want the Digital Photo Exam
Policies, Consent and Submit Data
NOTICE OF PRIVACY PRACTICES
Introduction
This notice explains how your health information may be used and shared, and how you can access this
information. Please read it carefully as your privacy is important to us.
Our Legal Responsibility
Jade Optical is committed to protecting the privacy of your health information, which we handle as
required by federal and state laws. This notice, effective from April 14, 2003, describes our
policies, which we may amend over time. You can always request a current copy from our office or via
the contact details below.
How We Use and Share Your Health Information
For Treatment: Your information may be shared with healthcare providers like opticians and
ophthalmologists to coordinate and manage your care.
For Payment: We use your information to bill and collect payment for services from you,
insurance companies, or other entities.
For Healthcare Operations: We may use your info for operational purposes, such as improving
quality, training staff, and getting certifications.
Your Choices and Rights
Authorizations: You may authorize us to use your information for other purposes or revoke such
authorization at any time.
Family and Friends: With your approval, or under certain circumstances, we may share
information with individuals involved in your care.
Public Requirements: We may disclose information when required by law, such as for legal
proceedings or in emergencies.
Patient Rights
Access:You have the right to see or get copies of your health information. A reasonable fee
may apply.
Restrictions:You can request restrictions on how we use or share your information, but we are
not required to agree to them.
Communication:You can ask us to communicate with you in a specific way or at a specific
location.
Amendments: You can ask us to amend your information if you believe it is incorrect or
incomplete.
Questions and Complaints
If you have any questions or concerns about our privacy practices or believe your rights have been
violated, please contact us using the information below. You also have the right to file a complaint
with the U.S. Department of Health and Human Services. We will not retaliate against you for filing
a complaint.