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Pembroke Pines Coral Springs 15651 Sheridan Street/ Ste 1000 9840 W. Sample Rd Davie, FL 33331 Coral Springs, FL 33065 (954) 252-8885 (954) 755-3750

Welcome!

How did you hear about us? (Check all that may apply)

q Walking/Passing By q From a Friend or Family Member. Please give their name(s)______ q Mailing and/or other announcement q Other source. Please list__________________________________

Name________________________ Date of birth: ______ Age: ____

Address_____________________________ Sex (Circle One) M F

City_________________________________ Zip Code_____________

Home Phone_______________________ Work Phone________________

Cell Phone________________________ E-mail____________________

Vision Insurance Plan______________ Social Security #____________

Occupation_____________________________ Last eye exam_________

Current Medications_____________________________________________

Allergies______________________ Name of Physician________________

Have you ever worn contact lenses? (Circle One) Yes No

Are you interested in wearing contact lenses? (Circle One) Yes No

By signing below, I affirm that I have read and understand the

Privacy Policy for Sheridan Eye Care that is attached on Pages 2 and

3, as well as agreeing to the Optical Policies section on Page 3.

Signature_______________________ Date__________________

As a policy, payment is due at time of services rendered.

S h e r i d a N

E Y E C A R E

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Notice Of Privacy Practices For Protected Health Information

This notice is being provided to you as a requirement of the federal Health Insurance Portability and Accountability Act (HIPAA). This notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created in or received by your health care provider, and that relates to your past, present or future physical health or condition. Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. Understanding what is in your medical record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

1 - How Medical Information About You May Be Used And Disclosed

We may use and disclose protected health information about you to provide you with medical treatment or services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you. For example, we may disclose information to people outside of our office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.

1.1 - For Treatment

We may use and disclose protected health information about you to provide you with medical treatment or services. We may disclose this information to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you. For example, we may disclose information to people outside of our office when scheduling tests, arranging consultations with other physicians, phoning in prescriptions, etc.

Privacy Policy 1.2 - For Payment

We may use and disclose protected health information to obtain reimbursement for the health care provided to you. We may also use this information to obtain prior authorization for proposed treatment or to determine whether your plan will cover the treatment. We will also share this information with our billing service as needed to facilitate their efforts towards reimbursement from you or your insurance company.

1.3 - For Healthcare Operations

We may use and disclose protected health information to support functions of our practice related to treatment and payment such as case management and quality assurance. In addition, we may use your health information to evaluate staff performance, to help us decide what additional services we offer, and other management and administrative activities.

1.4 - Appointment Reminders

We may contact you to remind you that you have an appointment or need a referral for an appointment.

1.5 - Treatment Issues

We may call you with test results, to tell you about treatment options or alternatives, or to respond to your phone call and answer questions about your treatment.

1.6 - Health-Related Benefits and Services

We may use and disclose medical information to tell you about health-related benefits, services or medical education classes that may be of interest to you.

1.7 - Individuals Involved in Your Care or Payment for Your Care

Unless you object, we may disclose your protected health information to your family or friends or any other individual identified by you when they are involved in your care or the payment for your care. We will only disclose the protected health information directly relevant to their involvement in your care.

1.8 - Emergencies

We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably possible after the delivery of your treatment.

1.9 - Communication Barriers

We may use or disclose your protected health information if we have attempted to obtain consent from you but are unable to do so due to substantial communication barriers and we determine that your consent to receive treatment is clearly inferred from the circumstances.

1.10 - Required by Law

We may use or disclose your protected health information when required by federal, state or local law. The disclosure will be limited to the relevant requirements of the law.

1.11 - Public Health Risks

We may use or disclose your protected health information for public health reasons in order to prevent or control disease, injury or disability; or to report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

1.12 - Communicable Diseases

We may disclose your protected health information, if required by law, to a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading the disease or condition.

1.13 - Health Oversight Activities

We may disclose protected health information to federal or state agencies that oversee our activities.

1.14 - Legal Proceedings

We may disclose protected health information in response to a court or administrative order or in response to a subpoena, discovery request or other lawful process.

1.15 - Law Enforcement

We may release protected health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process subject to all applicable legal requirements.

1.16 - Workers Compensation

We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally established programs.

1.17 - Military Activity and National Security

If you are, or were, a member of the armed forces or part of the National

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Security and Intelligence communities we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

1.18 - Business Associates

There may be some services provided in our organization through contracts with Business Associates. Examples include our billing services, answering services, web services, etc. When these services are contracted, we may disclose some of your protected health information to our Business Associate so that they can perform their job. To protect your health information, however, we require the Business Associate to appropriately safeguard your information.

1.19 - Other Uses and Disclosures of Health Information

Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described above. You may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on the use or disclosure indicated on the authorization.

2 - Your Health Information Rights

You have the right to inspect and obtain a copy of your protected health information. This means you may inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply. This request must be made in writing.

2.1 - Right To Inspect And Copy Your Protected Health Information

You have the right to inspect and obtain a copy of your protected health information. This means you may inspect and obtain a copy of your medical and billing records. A reasonable copying charge may apply. This request must be made in writing.

2.2 - Right To Request A Restriction On Uses And Disclosures Of Your Protected Health Information

You have the right to request a restriction on your protected health information. This means you may ask us to restrict or limit disclosure of any part of your protected health information. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or payment for your care. You must state the specific restriction requested and to

whom you want the restriction to apply. However, this request is subject to our approval. If the physician believes it is in your best interest to permit use and disclosure of your information, it will not be restricted. If the physician does agree to the requested restriction, we may not use or disclose your protected health information unless it is needed to provide emergency treatment.

2.3 - Right To Request To Receive Confidential Communications

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. You must make this request in writing and your request must specify how or where you wish to be contacted. We will not ask you the reason for your request.

2.4 - Right To Request Amendments To Your Protected Health Information

You have the right to request a correction to your protected health information. This means you may request an amendment of your medical record if you believe the health information we have about you is incorrect or incomplete. You must make this request in writing. Forms are available for this purpose and can be obtained from us. We may deny your request for an amendment if we feel it is inaccurate, or if the amendment you are requesting is part of the record that was not created by us. If we deny your request for amendment, you have the right to have your request and our denial added to your medical record.

2.5 - Right To Receive An Accounting

You have the right to receive an accounting of disclosures of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operation, or for disclosures that occurred prior to April 14, 2003. You must make this request in writing and this request must include a time frame, which may not be longer than 6 years or may not include dates prior to April 14, 2003.

2.6 - Right To Obtain A Paper Copy Of This Notice

You have the right to obtain a paper copy of this notice from us.

2.7 - Right To Register A Complaint

You have the right to register a complaint if you feel your privacy rights have been violated. If you believe your privacy rights have been violated, you may file a complaint with our office.

You may also file a complaint with the Secretary of the Department of Health & Human Services. You will not be penalized for filing a complaint.

3 - Changes To This Notice

We reserve the right to change this notice and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date at the top. You are entitled to a copy of the notice currently in effect. This notice will be posted on our website.

4 - Contacting Our Privacy Officer:

Amandip Sappal, O.D. 15651 Sheridan St Suite 1000 Davie,FL 33331 Tel (954) 252-8885 Fax (954) 252-8882

5 - Effective Date

This notice is effective June 27, 2005. Optical Policies Ophthalmic Frames = Ophthalmic frames may be returned within 30 days if they are in “re-sellable” condition. “Re-sellable” means that they are free of any defects, scratches, blemishes, hairs, oils, breaks, deformities, or chips. It is the patient’s responsibility to ask about a frame’s warranty. Discount frames have a maximum 60 day warranty. Sheridan Eye Care ultimately reserves the right to determine if a partial or full refund is given or not. Opthalmic Lenses = Ophthalmic lenses are considered custom orders made by an outside lab; therefore, they can not be refunded. If there is a prescription error, lens performance issue, or progressive non-adapt, every appropriate measure will be taken by Sheridan Eye Care to remedy the problem at no cost to the patient. Services = All fees for services are due at the time services are rendered. Sunglasses = No refunds are allowed on non-prescription sunglasses. All sales are considered final.

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Dilation Consent

Pupillary dilation is a safe and routine part of a comprehensive eye examination. However, this procedure does require the instillation of prescription eye drops that may keep your vision blurry and/or dilated for up to 24 hours. Your consent is required –and driving is not recommended for 3 hours after the exam. Pupillary dilation is strongly recommended to ensure ocular health as it allows the doctor to gather a complete set of information about your eyes. ___ Yes, I wish to have my pupils dilated. (Please note that on some extremely busy days such as Saturday, we may not have time to dilate the eyes –therefore, it may be necessary to reschedule it for a weekday at no additional charge to you.) ___ No, I do not wish to be dilated at this time. I understand that this may keep the doctor from making a full assessment of my ocular health. Signature:____________________________Date:________________________ (Patient Signature, Parent or Guardian if patient is a minor)

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Instructions for Handling Contact Lenses Wash your hands before handling your lenses. Do not use any soap containing cream, lotion, oil, or perfume. Keeps nails short, filed and clean.

Soft Contact Lens Instructions

Never let soft contact lenses become dry. Never soak them in tap or distilled water. If lenses dry out, they will become brittle. Should this occur, however, soak the lenses in saline for two to three hours. Then, if the lenses do not appear damaged, continue with your disinfecting regimen. If the lenses are uncomfortable after you insert them, remove them immediately and call us.

You will be given solutions and instructions to care for your lenses. Always clean the lenses first and then disinfect them. To clean, put a small amount of solution in the palm of the hand and rub the lenses to remove any loose debris on the surface. After rubbing the lenses, rinse thoroughly with saline and continue with the disinfecting segment of the care system. Store the lenses in the disinfecting solution until you are ready to reinsert them. Take them directly from the storage solution and insert them in the eyes. A lens should never be inserted that has not been disinfected by the system provided.

Soft Contact Lens Schedule

Day Wear Time (Hours)

1 4

2 6

3 8

4 10

5 12

6 12

7 12-14

(Maximum wearing time will be determined at your follow-up appointment.)

Remember to clean and disinfect your lenses if they are stored more than 48 hours. DO NOT RUSH YOUR WEARING TIME!

Possible Contact Lens Complications

Wearing contact lenses is a reasonable method of attaining good vision as an alternative to glasses. However, wearing contact lenses is not without risk. The following conditions are possible complications of contact lenses.

You must be aware of the potential hazards and accept these relative risks in addition to the benefits of contact lenses.

1. Contact Lens Overwear. This occurs when the contact is worn longer than the cornea can tolerate. Not enough oxygen gets to the cornea resulting in temporary discomfort and blurred vision. The treatment is to discontinue wearing the contact lenses for a few days.

2. Corneal Abrasion. This is a "scratch" on the surface of the cornea resulting from a poorly-fitting contact lens, foreign material under the contact lens or overwear. The treatments include antibiotics and possible patching of the eye. Infection may result from this condition.

3. Allergic Reaction. In this condition the eye becomes red and irritated in response to the cleaning and/or storage solutions. It is most often seen with soft contact lenses and is usually a reaction to the preservatives in these solutions. Treatment includes changing to different solutions and storage methods as directed by your doctor.

4. Tight Lens Condition. This is mot often seen with soft and extended wear contact lenses. The lens, which previously had fit well, "tightens up" and does not allow teas and oxygen to the cornea. This results in pain, redness, and swelling of the cornea and can lead to a corneal abrasion. The treatment is to refit the lens.

5. Corneal Warpage. This is most often seen with hard and gas permeable contact lenses. In this condition, the shape of the cornea becomes altered in response to the contact lenses. If severe warpage occurs, the lenses may no longer fit well and discomfort results. The treatment is to discontinue wearing the contact lenses until the warpage resolves, which may take weeks to months. During this healing time, the vision may fluctuate, requiring a change in the glasses prescription one or more times. Occasionally, the warpage may not resolve and the astigmatism created may persist.

6. Giant Papillary Conjunctivitis (GPC). In this condition, there is itching, lens intolerance, and redness while wearing the contact lenses. It is more often seen with soft lenses and is generally caused by a buildup of

protein on the surface of the lens. Treatments include discontinuing lens wear for a period of time, switching lens types, and switching solutions.

7. Corneal Ulcer. This is the most severe complication of contact lenses and is more often seen with extended wear soft lenses. In this condition, trauma or contamination to the cornea from the contact lens results in an infection. This sometimes requires hospitalization for treatment and can lead to extensive corneal scarring. Corneal transplant surgery may be required to regain good vision. Although very rare, it is possible that a patient could lose an eye from a severe corneal ulcer.

It is not possible to determine in advance whether you will become a successful contact lens wearer or not. Personal, physiological and environmental factors may require changes in the wearing schedule or termination of lens wear. Please keep your glasses prescription up-to-date in case you are unable to wear your lenses.

Adhering to the lens care system recommended is important. The risk of complications increases when you do not adhere to the lens care system prescribed for you. Switching or mixing products could cause irritation and/or permanently discolor your lenses.

A lens should be brought back to your eye doctor for evaluation if:

1. It accumulates deposits, is no longer comfortable, or becomes discolored and cannot be restored to its original condition using the methods in this pamphlet.

2. It becomes scratched, chipped, or cracked.

If you experience redness, secretion, visual blurring, or pain (RSVP), remove your contact lenses at once. If the symptom subsides, the lenses can be cleaned and reinserted. If the lenses are removed and the symptom does not subside or reappears upon reinsertion, remove the lenses immediately and call us!

Contact lenses require proper care and handling. They must pass many rigid tests to insure proper power, shape, and durability. Contacts do not develop tears, nicks, or scratches by themselves. They are only caused through mishandling of the lenses by the patient. How well you care and handle them will determine how long they last. You must follow all instructions in caring for and handling your lenses. Failure to do so could damage your lenses. The average patient will replace at least one lens per year. Lost, damaged, or contaminated lenses will not be replaced free of charge.

Contact lens fitting requires a number of follow-up visits (two to three visits in the first three months). These visits are very important to ensure the proper fit of the lens and the health of the eye. Please keep all appointments made for you.

Contact lens evaluations and fittings are mandatory yearly for a prescription refill.

A contact lens prescription does not exist until the doctor deems your lens fit acceptable after several checks during follow-up care. After you have been released from initial follow-up care, you may request a copy of your contact lens prescription.

Your cooperation is vital to your success in wearing contact lenses.

DO clean rigid gas permeable lenses in the palm of your hand instead of between your fingers. Clean from center to edge rather than in a circular motion.

DO's and DO NOT's

DO

• DO keep soft lenses moist to prevent tearing.

• DO add a rewetting drop before removing contact lenses.

• DO wet lenses with saline before picking them up from a dry surface or cleaning them to prevent tearing or warpage.

• DO buy a case with ridges in the bowl and the lid to prevent suction of the lens to the case.

• DO apply cosmetics sparingly.

• DO purchase hypoallergenic, nonflake cosmetics. Some cosmetics are made specially for use with contact lenses.

• DO discard eye makeup three months after opening. The exception is pencil eyeliner that is sharpened to a fresh supply.

• DO insert lenses BEFORE applying cosmetics.

Sheridan Eye Care Contact Lens Instruction Packet

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• DO remove lenses BEFORE removing cosmetics.

• DO remove cosmetics daily with an oil free, hypoallergenic remover.

• DO follow your eye doctor's instructions for lens care and use only the solutions recommended by your eye doctor.

• DO keep your contact lens case clean. Scrub lens case weekly with toothbrush and daily cleaner.

• DO carry a case with you with fresh solution in it at all times.

• DO remove your lenses and consult your eye doctor, if you experience redness, itching, irritation or pain.

DO NOT

• DO NOT touch the tip of your bottles with your fingertips or touch your eye with the bottle tip when instilling lubricating drops.

• DO NOT hold a rigid gas permeable lens by the edges. Hold it front to back.

• DO NOT slide a rigid gas permeable lens across a flat surface.

• DO NOT use hair spray when your lenses are in. Spray your hair BEFORE inserting your lenses.

• DO NOT use saliva to wet your lenses. Your mouth is full of bacteria.

• DO NOT sleep in your lenses unless instructed by your eye doctor.

• DO NOT use cosmetics or contact lenses if your eyes are irritated or red.

• DO NOT share cosmetics.

• DO NOT reuse a mascara or eyeliner wand in refills.

• DO NOT apply eyeliner to the inner margin of your eyelid.

• DO NOT use waterproof mascara. It is very difficult to clean off lenses.

• DO NOT use lash-builder mascara. It contains nylon and/or rayon fibers which can be irritating if they drop into the eye.

• DO NOT use frosted eye shadow unless it has been specially formulated for use with contact lenses.

• DO NOT apply cosmetics or lenses in a moving vehicle.

• DO NOT separate clumped eyelashes with sharp instrument.

Contact Lens Agreement and Patient Responsibility Please read carefully the following four paragraphs that follow, for they constitute your obligations as a contact lens patient of Sheridan Eye Care. I have been instructed in the proper methods of lens care and handling. I understand the importance of adhering to proper lens care procedures and the need for periodic progress evaluations. I agree to follow the recommended wearing schedule and to keep scheduled appointments. I agree to follow my doctor’s advice for the safe wear of lenses as indicated on this form in my record of care. I will notify my doctor or Sheridan Eye Care immediately if any eye or vision problem occur. I understand that contact lenses are medical devices and are dispensed up to one year from the date of the examination. Disposable trial lenses are for fitting purposes only and will be dispensed at the initial fitting exam only. I understand that I should have a pair of glasses as a back-up to contact lenses if correction is needed. I know that there are safer, more-feasible alternatives to daily, extended, or continuous wear (overnight) contact lenses including gas permeable contact lenses and spectacles, that are available to me. I understand that extended or continuous wear (overnight) contact lenses have many benefits but, as with any other drug or medical device, they are not without risks. I have been told that the risk of complications with extended or continuous wear (overnight) lenses is greater than for daily wear lenses or gas permeable lenses. I have also been told that a small percentage of wearers develop serious complications, including conditions that can cause permanent injury and vision loss. For this reason, I agree to follow the advice and instructions provided by my doctor. I will remove my lenses immediately if I experience eye pain, redness, discharge, sensitivity to light, or decreased vision. I also understand that contact lenses alone do not provide adequate protection from the ultraviolet rays of the sun and that UV-blocking sunglasses should be worn over contact lenses for outdoor activities. Contact lens prescriptions will be released to the patient after the follow-up period upon request. I understand that not all contact lenses are designed for overnight wear and if I am fit with extended wear lenses that the maximum approved wearing time is six nights in a row. It is the doctor’s discretion to determine if I can safely wear extended wear contact lenses. Contact lens examination fees, as with all other professional fees, are non-refundable. Contact lens examinations include follow-up visits for 60 days after the fitting exam. We will schedule your follow-up appointment; however, it is the patient’s responsibility to make sure that the follow-up is completed within the 60 day time period. If you fail to keep scheduled follow-up visits during the 60 day period, additional office visit charges may apply. Please Sign, Print Name, and Date __________________________________________________________Signature __________________________________________________________ Print Name ___________________________________________________________Date

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Name____________________________ Date___________ Instructions: Please answer the following questions about how your eyes feel when reading or doing close work. Check the appropriate column below.

Never Infrequently Sometimes Fairly/Often Always

1 Do your eyes feel tired when reading, using a computer or doing close work?

2 Do your eyes feel uncomfortable when reading, using a computer or doing close work?

3 Do you have headaches when reading, using a computer or doing close work?

4 Do you feel sleepy when reading, using a computer or doing close work?

5 Do you lose concentration when reading, using a computer or doing close work?

6 Do you have trouble remembering what you have read?

7 Do you have double vision when reading, using a computer or doing close work?

8 Do you see the words move, jump, swim, or appear to float on the page when reading, using a computer or doing close work?

9 Do you feel like you read slowly? 10 Do your eyes ever hurt when reading,

using a computer or doing close work?

11 Do your eyes ever feel sore when reading, using a computer or doing close work?

12 Do you feel a “pulling” feeling around your eyes when reading, using a computer or doing close work?

13 Do you notice the words blurring or coming in and out of focus when reading, using a computer or doing close work?

14 Do you lose your place while reading, using a computer or doing close work?

15 Do you have to re-read the same line of words when reading?

Total Xs in each column X0 X1 X2 X3 X4

Score____________

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