New Patient Check In - One Page Form

Patient Name:*

DOB:*

Example: 11-20-1950

Today's Date:*

Address:*

Home address, city, state, zip.

Email:*

example@example.com

Phone:*

Area CodePhone Number

Is this a cell phone?*

YesNo

Patient's SSN:*

Sex:*

MaleFemale

Preferred Pharmacy: *

City:

Cross Streets:

Phone Number:

Area CodePhone Number

CVO is proud to offer the best possible care for their patients. Because of this, we recommend the Optomap for every one annually. Sometimes referred to as ultrawide imaging, Optomap gives your doctor a nearly complete view of your retina and allows for state-of-the-art assessment of the overall health of your eye by allowing your doctor to see things out in the far parts of your eye that might otherwise be missed such as tumors, tears, and detachments. Dilation, which is part of every thorough eye examination, allows your doctor to see the back of your eye in 3-dimensions and with a level of details not otherwise possible. Together, Optomap and Dilation provide the greatest level of assurance that the back of your eye is thoroughly evaluated.

Your doctor recommends that you get dilation in addition to the Optomap image.

Please select ONE option below*

I ELECT to have both DILATION (no additional cost) and OPTOMAP RETINAL IMAGING for $25.I ELECT to have OPTOMAP RETINAL IMAGING for $25 but I am DECLINING DILATION. I understand that this increases the risk of partial or total loss of vision due to undetected eye disease.I DECLINE the OPTOMAP RETINAL IMAGING but I am CHOOSING to be DILATED.I DECLINE both OPTOMAP RETINAL IMAGING & DILATION. I understand that this creates the greatest risk for partial or total loss of vision due to undetected eye disease.

Please be advised that any records and all finalized prescriptions, spectacle, contact, or otherwise, will be uploaded and made available to you electronically via your Patient Portal.

You can access and register for this portal at: www.mysecurehealthdata.com.

By signing below, you acknowledge and accept electronic receipt of prescriptions and records.

Insurance Authorization and Financial Privacy Notice:

Insurance Authorization and Financial Agreement Privacy NoticeI here authorize Coachella Valley Optometry (CVO) to release my information to determine the benefits payable for related services to any insurance carrier I have. I hereby authorize payment directly to CVO from my insurance including deductibles, coinsurances, and non-covered services. I agree it is my responsibility to know which providers are in my network and which services are covered by my plan. I also agree that proof of Insurance eligibility does not guarantee payment by my insurance and I will be held responsible for any fees not covered by or paid by insurance.

Signature of patient or legal guardian*

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New Patient Check-In Form