Online Patient Registration Form

Name: 20/20 Eye Care Center
Address: 1839 W Orangethorpe Ave, Fullerton, CA, 92833, US
Telephone: (714) 879-2020

lock icon Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address
Please provide us your email address.
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Please enter a number from 0000 to 9999.
Preferred Language*
Race*
Ethnicity*
Primary Language?*
- Select All
- English
- Spanish
- Korean
- Other
Which Other Language?*
Marital Status
Marital Status - Other
Please provide your marital status.
Employment Status
Employment Status - Other
Please provide your employment status.
Employer
Occupation
How were you referred to our office?
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
Eye History
When was your last eye exam?*
Please check off any current conditions you suffer from
Blurred Distance Vision*
- Yes
- No
Blurred Near Vision*
- Yes
- No
General Blurred Vision*
- Yes
- No
Want Contact Lenses*
- Yes
- No
Itch burn or Tear*
- Yes
- No
Double Vision*
- Yes
- No
Amblyopia*
- Yes
- No
Cataracts evaluation*
- Yes
- No
Dry Eyes*
- Yes
- No
Broken Glasses*
- Yes
- No
Flashes of Light*
- Yes
- No
LASIK*
- Yes
- No
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:
Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription
Medical History
Who is your primary doctor?*
Primary Doctor's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you pregnant?
- Yes
- No
Do you have a problem with these systems?
Gastrointestinal*
- Yes
- No
Diabetes*
- Yes
- No
Urinary*
- Yes
- No
Allergies*
- Yes
- No
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)*
- Yes
- No
Drugs*
- Yes
- No
Ears/Nose/Throat*
- Yes
- No
Migraines*
- Yes
- No
Bones*
- Yes
- No
Drinking/Alcohol*
- Yes
- No
Allergic/Immune System*
- Yes
- No
Cardiovascular*
- Yes
- No
Use Tobacco*
- Yes
- No
Skin issues*
- Yes
- No
Mental issues*
- Yes
- No
Thyroid*
- Yes
- No
Respiratory*
- Yes
- No
Nervous*
- Yes
- No
High Blood Pressure*
- Yes
- No
Endocrine*
- Yes
- No
Other*
- Yes
- No
List of Medicines, for which conditions?
Primary Vision Insurance
Please bring all insurance cards with you to your appointment.
Vision Insurance Company Name
For example: VSP, Eyemed, Davis, Spectera etc
Vision Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Primary Medical Insurance
Medical Insurance Company Name
For example: Aetna, Blue Cross, Blue Shield, Care First, Cigna etc
Medical Insurance Company Phone Number
HMO or PPO?
- HMO
- PPO
What's the HMO Group Name?*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Additional Fees and Insurance Policies
ADDITIONAL FEES AND INSURANCE POLICES
* There are additional fees for Contact Lens Evaluation. Please inquire
* We make no guarantees with YOUR insurance in coverage or payment. Any fee quotes with insurance are ESTIMATES only. There may be money you owe after your visit due to insurance shortages or denials.
* Any shortfall in payment is the patients Responsibility and you agree to pay us promptly when notified.
Signature
Date
MM slash DD slash YYYY
The Digital Image (Photo) and Scan of Your Eye
To provide a complete health assessment of the eye each patient to have a Digital Image and a Scan of the eye at every annual eye exam. This will be provided at your insurance co-pay rate and explained at the time of the exam.
- Yes
- discuss with doctor
Patient Signature
Information Regarding Dilating Eye Drops - Is Today Ok?
The Doctor may want to dilate your eyes and will talk you about it during the eye exam. If so you need to decided if today is a good day because with dilation your pupils will become unusually large and you will have blurring of vision for around 2 to 4 hours , especially for things that are close to you. Sunglasses will be provided for you because you will be sensitive to light. Driving may be difficult after an dilation for some patients , if that happens to you it’s best if wait for the effects to wear off or you make arrangements not to drive yourself. Do not operate machinery.
DILATING DROPS are used to dilate or enlarge the pupils of the eye to allow the Eye Doctor to completely evaluate the health of your eyes. Without dilation the Doctor can not get a full view of your eye to do a complete health evaluation.. Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.
IF YOU HAVE PAIN IN YOUR EYES A FEW HOURS AFTER DILATION SEEK CARE AT THE ER, URGENT CARE, OR THOUGH YOUR INSURANCE AGREEMENTS. CALL OUR OFFICE FOR ADVICE.
Please report to the Doctor if you have been dilated before and had some adverse side effects.
Is today ok to dilate your eyes?
- Yes - today is ok
- I would like to discuss with Doctor
- No - I decline
- Not a good day. I would like to appoint for a different day. A office visit fee applies
- No - I see a specialist for my eyes
Notice Of Privacy Practice
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE IS EFFECTIVE 12/12/02 UNTIL FURTHER NOTICE.
Right to Notice As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA). Dr. Chiana’s Eyecare Center can use your protected health information for treatment, payment and health care operations. a) Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. b) Payment - We may use and disclose your health information to obtain payment for services we provide you. c) Health care operations - We may use and disclose your health information in connection with our healthcare operations..
Your Authorization Most uses and disclosures that do not fall under treatment, payment, health care operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.
Emergency Situations In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.
Marketing We will not use your health information for marketing communications without your written authorization.
Required by Law We may also use or disclose your health information when we are required to do so by law.
Abuse or Neglect We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes
National Security We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances.
Appointment Reminders We may use or disclose your health information to provide you with appointment reminders via phone, e-mail or letter.
Your Rights as a Patient You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations. -You have the right to receive confidential communications regarding your protected health information. -You have the right to inspect and copy your protected health information. -.
Legal Requirements Dr. Chiana’s Eyecare Center is required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice.
Complaints If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office..
Contact Information For further information about Dr. Steven J Chiana’s Eyecare Center’s privacy policies, please contact Dr. Steven J. Chiana Eyecare Center 1839 w Orangethorpe ave, Fullerton Ca 92833 (714) 879-2020 Dr. Steven Chiana or supervisior I understand that the above refers to my rights under the Health Insurance Portability and Accessibility Act (HIPAA). I may ask for a copy of this.
Signature
Date
MM slash DD slash YYYY
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Name
This field is for validation purposes and should be left unchanged.

Patient Information

Personal Information

Eye History

Please check off any current conditions you suffer from

Glasses History

Contact Lens History

Medical History

Do you have a problem with these systems?

Primary Vision Insurance

Primary Medical Insurance

Secondary Insurance

Additional Fees and Insurance Policies

The Digital Image (Photo) and Scan of Your Eye

Information Regarding Dilating Eye Drops - Is Today Ok?

Notice Of Privacy Practice

Comments

Privacy Policy

20/20 Eye Care Center

20/20 Eye Care Center

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