Patient Information

Step 1 of 6

Patient Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone
Email*
Sex*
- Male
- Female
Birthdate*
Last 4 of SSN*
Occupation
Employer
Marital Status
Spouse's Name
First Last
Spouse's Birthdate
Spouse's Last 4 of SSN
Spouse's Occupation
Spouse's Employer
Emergency Contact
Name*
First Last
Relationship*
Phone Number*
Alternate Phone
Primary Care Physician
Who may we thank for your referral?
Date*
MM slash DD slash YYYY
Signature*

Social History
Health Habits Which substances do you use and note consumption.
Do you use alcohol?*
- Yes
- No
Quantity
Do you use drugs?*
- Yes
- No
Quantity
Do you use tobacco?*
- Yes
- No
Quantity
Ocular History: Please indicate any ocular conditions you currently have, or none.*
Ocular Surgeries: (please indicate right or left)*
Patient signature attesting to accuracy of medical history*

Medications
Patient Name*
First Last
Patient Date of Birth*
Allergies/Reactions
Please list medications, dosages, and frequency.
Date*
MM slash DD slash YYYY
Signature*

HIPAA Consent Form
Spectrum Eye Gallery, Inc., provides this Consent to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996(HIPAA)
We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.

This is a summary of and consent for the privacy practices and patient care at Spectrum Eyewear Gallery, Inc., and services as a condensed version of our Notice of Privacy Practices. You have the right to review our Notice before signing this consent upon request. The terms of our Notice may change and you may obtain a revised copy by contacting our office.

If you ever believe your privacy rights have been violated you may file a complaint with the Compliance Officer of Spectrum Eyewear Gallery, Inc., or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. you will not be penalized for filing complaints.

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.

How will we use or disclose your information? Here are a few examples:
- For vision, medical eye treatment, and referral
- To obtain payment and file insurance
- In emergency situations
- For appointment and patient recall reminders
- To run our practice more efficiently and ensure all our patients receive quality care.
- For research and education
- Prevent serious threats to health safety
- For organ and tissue donation
- For workers' compensation programs
- In response to certain request arising out of lawsuits or other disputes
You have certain rights regarding the information we maintain about you. These rights include:
- The right to inspect and copy
- The right to amend
- The right to an accounting of disclosures
- The right to request restrictions
- The right to a paper copy of this notice
- The right to request confidential communications
By signing this form, you consent to our use and disclosure of protected health information about your for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent.

Additionally, by signing this form, you acknowledge that by presenting yourself as a patient or child you consent for vision medical eye care by the doctors and staff of Spectrum Eyewear Gallery, Inc. You hereby grant full authority to the optometrists/ophthalmologists, and their respective assistants to administer and perform any and all drugs, treatments, test, or diagnostic procedures to or upon me, which may be advised, or necessary.

This information and Notice of Privacy Practices is made available on request.
Patient Name*
First Last
Date*
MM slash DD slash YYYY
Signature*

ALL SALES AT SPECTRUM EYEWEAR GALLERY ARE FINAL
At Spectrum Eyewear Gallery, we value each and every one of our patients. We want you to be 100% satisfied with the quality of your eyewear and the way you look. Please keep in mind that if you are unsure of your purchase, Spectrum has a hold policy, where we can hold the frame for up to two weeks at no charge to you. Spectrum offers a one-year, one-time manufacturer's replacement warranty on all of our frames and lenses. All items returned for warranty replacement must be presented for return.
- If the prescription of your glasses needs to be altered, we will replace the lenses at no charge to you within 30 days of dispense.
- If you decide within 24 hours of you purchase that you are no longer satisfied with what you have selected, please notify the office and you will be issued an in-store credit for the full amount of what you paid.
- If you decide after the 24 hour period that you are not happy with what you have chosen, you may choose a new frame. You will be responsible for any additional cost above the amount of the original frame. Spectrum will split the cost of the new lenses with you.
- Contact may be returned for store credit as long as the box remains unopened.
By signing this document you have the acknowledged Spectrum Eyewear Gallery's policy that all sales are final and that the form of payment used may not be replaced with any other form of payment or insurance after the sale, and that no refunds will be issued.
Date*
MM slash DD slash YYYY
Signature*
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Patient Information

Patient Information

Step 1 of 6

Emergency Contact

Family History

Social History

Medications

HIPAA Consent Form

ALL SALES AT SPECTRUM EYEWEAR GALLERY ARE FINAL