Online Patient Forms

Office Phone: (818) 900-5650

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

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Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

Insurance Name:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Patient Eye History

Patient Ocular Conditions

Ocular History

Eye Medications

Family Eye History

Glaucoma

Macular Degeneration

Retinal Detachment

Cataract

Amblyopia / Strabismus

Blindness

Other Family Eye Conditions

Family Medical History

Diabetes

Hypertension

Thyroid

Heart Disease

Cancer

Other Family Medical Conditions Family History Unknown

Patient Medical History

Endocrine:

YrDx

A1c

Allergic/Immunologic:

Musculoskeletal:

Cardiovascular:

Constitutional(Current):

Ears, Nose, Throat:

Gastrointestinal:

Genitourinary:

Integumentary (Skin):

Lymphatic/Hematologic:

Neurological:

Psychiatric:

Respiratory:

Other Patient Medical Conditions

Medications No current medications

Allergies No known drug allergies

Primary Care Physician

Referring Physician

Referring Physician Phone

Other Physicians

Last Medical Dr Appt

Smoking Status

Alcohol Use

Illegal Drug

Race

Preferred Language

Ethnicity

Dry Eye Questions

Do you use eye drops?

Do you experience: burning, itching or tearing in your eyes?

Does your vision fluctuate?

Policies, Consent, Submit Data

NOTICE OF PRIVACY PRACTICES
View Notice of Privacy Practices Form

Patient Signature

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Patient Responsibility Statement Your medical insurance and/or vision discount plan is not a substitute for payment. You may have both medical insurance (Aetna, Anthem, Blue Shield, Cigna, etc) and a vision discount plan (VSP, EyeMed, Spectera, etc). It is important that you understand that vision discount plans do not cover medical eye problems , and that most medical insurance does not cover routine vision problems.

Vision discount plans cover routine exams only and may help pay for glasses or contact lenses. Medical Insurance covers exams where any medical condition that can affect the eyes is evaluated. Examples of medical eye problems include: eye allergy, irritation, dry eye, glaucoma, diabetic retinopathy, cataracts, etc).

After your examination, the doctor will determine to which insurance the exam must be filed. We are a provider on most major vision and medical plans. If we are a provider for your insurance, we will file a claim to your primary insurance carrier as a courtesy. In the event we are not on your provider's panel, we will provide an itemized receipt so that you may file the claim yourself.

If you have a secondary insurance, and the co-pays or co-insurance is not automatically transferred, you will receive a statement and you must file the secondary claim. The balance on that statement is your responsibility. Avant Eyes cannot provide a secondary claim filing service.

Your complete insurance information/card must be presented at the time services are provided and updated as necessary. Accurate and complete insurance information must be provided so we may assist you in filing your claim promptly.

You will be responsible for any co-pays, co-insurance and/or unmet deductible that your insurance carrier deems patient responsibility. You are also responsible for any non-covered services. Our office does not make these rules; they are defined by the insurance carriers themselves. We are contractually obligated to collect your portion of the fees as indicated by your insurance carrier It is your responsibility to know your insurance benefits and coverage.

By signing this statement, you agree to be financially responsible for all charges. Additionally, you authorize our office to utilize any personal/medical information needed to determine benefits payable for related services. This form will remain in effect until revoked by written notice.

Patient Signature

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Updates to Office Policies 2024 We have updated our policies as outlined below:

1. Same Day No-Show/Cancellation Policy: We make every effort to send appointment reminders 3 days prior to your scheduled appointment, 24 hours before and the day of your appointment. We now require 24 hours notice to cancel/change your appointment. Any notice provided to our office within less than 24 hours or same day (whether by phone, call or voicemail) will be assessed a SAME DAY CANCELLATION FEE of $50.

2. Pursuant to Health and Safety Code sections 123100 - 123149.5 your medical record is the property of the medical practice/facility that prepares them. Any requests for copies of medical records will be assessed a $25 fee, whether printed or emailed. These requests can take seven to ten business days to process. Please request medical records in writing to info@avanteyes.com.

3. Please complete the following to designate your emergency contact, to whom you give permission to release your medical record and/or allow the office to contact on your behalf in the case of an emergency:

Name

Relationship to Patient

Daytime Phone Number

4. The physicians at Avant Eyes Optometry & Advanced Dry Eye Center employ assistance of a virtual medical assistant who is âpresentâ in the exam room in realtime. The virtual medical assistant facilitates efficient use of physician time and documentation of your medical record and abides by all rules and regulations as outlined by HIPAA.

By signing this statement, you agree to be financially responsible for all charges as outlined above, as applicable. This form will remain in effect until revoked by written notice.

Patient Signature

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Dilation and Retinal Photos It is our policy that all patients have Retinal photos and OCT done at the time of their comprehensive exam. This technology helps the doctor detect serious health problems and oftentimes alleviates the need for the eyes to be dilated. After your insurance discount, the cost of this test is $39 (in addition to your exam copay/fee).

Mandatory retinal imaging will remain as the standard of care at Avant Eyes, unless you are under the care of a retina specialist and notes are provided 48 hours prior to your visit.

By signing this statement, you agree to be financially responsible for all charges. This form will remain in effect until revoked by written notice.

Patient Signature

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20165 Rinaldi Street, Suite 150, Porter Ranch CA 91326
818-900-5650 • www.avanteyes.com • 818-900-5651