Patient Record Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth MM slash DD slash YYYY AgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Alternate PhoneEmail Reason for Today’s Visit Would you be interested in Dry Eye Treatment? Yes No Please list your current medications* Any allergies to medications? RETINAL PHOTOGRAPHS* RETINAL PHOTOGRAPHS ARE STRONGLY RECOMMENDED BY ALL EYE SPECIALISTS IF YOU HAVE NOT HAD AN EYE EXAM WITH A SPECIALIST IN THE PAST 6 MONTHS, THE DOCTOR WILL TAKE RETINAL PHOTOS OF YOUR EYES. THIS IS TO ASSESS THE HEALTH OF THE EYE MORE THOROUGHLY AND IT GOES HAND IN HAND WITH DILATION. YOUR INSURANCE COPAY FOR PHOTOS IS $39 or $45.Patient / Representative / Parent Signature*DILATION OF THE PUPILS: This is the only way to have a thorough and complete eye examination. Health problems such as glaucoma, cataracts, retinal degeneration or tears, diabetes, high blood pressure and some tumors may be detected even before the onset of symptoms or loss of vision. Dilation will temporarily result in blurred vision and sensitivity to light for about 2-4 hours. Dilation Preference:* I prefer to have a complete eye exam that includes dilation. I prefer to have a complete eye exam, but would like to defer or reschedule the dilation. I understand that if I choose not to have the dilation, there may be diseases, defects, lesions, or other problems of the eye or body associated or not associated with pain, vision loss, or other symptoms that were not examined or ruled out today; and as a result, I do not hold Stephanie Cortes O.D., Howell Cohen O.D., Cortes Eye Care, or their associates liable for any delay in diagnosis and treatment that may have resulted from my deferring dilation today. I understand that it is my or my guardian’s responsibility to reschedule this portion of the exam.Hidden I prefer to have a complete eye exam that includes dilation.Hidden I prefer to have a complete eye exam, but would like to defer or reschedule the dilation. I understand that there may be diseases, defects, lesions, or other problems of the eye or body associated or not associated with pain, vision loss, or other symptoms that were not examined or ruled out today; and as a result, I do not hold Stephanie Cortes O.D., Howell Cohen O.D., Cortes Eye Care, or their associates liable for any delay in diagnosis and treatment that may have resulted from my deferring dilation today. I understand that it is my or my guardian’s responsibility to reschedule this portion of the exam.Signature*INSURANCE RECIPIENTS* I authorize the release of any medical or other information necessary to process my insurance claims. I also accept request of government benefits either to myself or to the party who accepts assignment, further authorizing payment of medical benefits to the undersigned physician or supplier for services rendered. I understand that my signature on this form will serve as a permanent signature on file and will be used for accept assignment purposes only.Vision Plan Company Vision Plan ID Medical Insurance Company Insurance ID Insured Name Insured Date of Birth MM slash DD slash YYYY Supplemental Insurance if Primary is Medicare Insurance ID Insured Name Insured Date of Birth MM slash DD slash YYYY Insured Signature*HiddenDate MM slash DD slash YYYY If you wish to view and/or download a copy of our Notice of Privacy Practices, please click here HIPAA ACKNOWLEDGMENT* My signature confirms that I have been provided with a copy of the Notice of Privacy Practices (NPP) of Stephanie Cortes O.D. or Cortes Eye Care, and have been offered a copy of such policy to keep for my records.HIPAA Signature*HiddenDate MM slash DD slash YYYY PATIENT’S MEDICAL HISTORY QUESTIONNAIREHiddenToday’s Date MM slash DD slash YYYY Patient’s Ocular History (Please check yes for any conditions that are present in your or your family’s history)Crossed Eyes (Strabismus)?* Yes No If Yes, Who? Blindness?* Yes No If Yes, Who? Glaucoma?* Yes No If Yes, Who? Macular Degeneration?* Yes No If Yes, Who? Retinal Detachment?* Yes No If Yes, Who? Lazy eye (Amblyopia)?* Yes No If Yes, Who? Eye Injury?* Yes No If Yes, What? Surgery?* Yes No If Yes, What? Infection?* Yes No If Yes, What? Patient’s Social History (strictly confidential, you may opt to leave this portion blank or discuss these items directly with the doctor) Patient’s Review of Systems Please check any current or past history CONSTITUTIONAL CONSTITUTIONAL (Cancer, Weight gain/loss) INTEGUMENTARY INTEGUMENTARY (skin) NEUROLOGICAL Epilepsy/Seizures Headaches/Migraines Multiple Sclerosis Stoke/CVA EYES Blurred Vision Burning Chronic Infection of Eye or Lid Distorted Vision/Halos Double Vision Dryness Excess Tearing/Watering Eye Pain or Soreness Flashes/Floaters in Vision Foreign Body Sensation Glare/Light Sensitivity Itching Loss of Side Vision Loss of Vision Mucous Discharge Redness Sandy/Gritty Feeling Stye or Chalazion Tired Eye ENDOCRINE Diabetes Thyroid/Other Glands AUTO-IMMUNOLOGIC AUTO-IMMUNOLOGIC (Lupus) PSYCHIATRIC PSYCHIATRIC EARS, NOSE, MOUTH, THROAT Allergies/Hay Fever Chronic Cough Dry Throat/Mouth Hearing Loss Post-Nasal Drip Runny Nose Sinus Congestion RESPIRATORY Asthma Chronic Bronchitis Emphysema Sleep Apnea VASCULAR/CARDIOVASCULAR Heart Disease High Blood Pressure Vascular Disease GASTROINTESTINAL Acid Reflux Ulcer GENITOURINARY Genital/Kidney/Bladder Pregnant Prostate Disease BONES/JOINTS/MUSCLES Joint Pain Muscle Pain Rheumatoid Arthritis LYMPHATIC/HEMATOLOGIC Anemia Bleeding Problems Cholesterol Patient Fees and Payment Policies A. PAYMENT Payment will be collected at time of service Checks denied for lack of funds will incur a fee of $35.00 All balances must be paid within 30 days of the invoice date. We will either mail or text your outstanding invoice. Please give us a current address and phone number if we need to contact you. An administrative fee of $40.00 will be added to any unpaid balance that is over 30 days past invoice. Patient and/or Patient parent/guardian will be responsible for collection fees if account balance is turned over for collections. In some cases, the non-payment will be sent to a small claims court. We require 24 hours notice, received during normal business hours, for any patients to cancel or change an appointment. If you miss an appointment, you may be charged a $50 no show fee. We reserve the right to make changes to our fees and/or policies without advance notice. B. INSURANCE You are responsible for your copay/coinsurance at the time of service. Stephanie Cortes OD PA staff will submit, on your behalf, to your insurance company for reimbursement for services. You are responsible for all remaining deductible and coinsurance amounts. C. CONTACT LENS EXAMS The contact lens fitting includes trial lenses, corneal topography, and corneal assessment to properly fit your contact lenses. All fees are due at the time of service and they are non-refundable. You are responsible to return for your follow up appointment as determined by the doctor. If you don’t return for your follow up within 6 months of your exam, then you will be charged for a new contact lens exam. Contact Lens application and removal training: The fees for Contact Lens Training are $20 each session. Consent* I hereby state that I have read and will abide by the Patient fees and Payment policies as advised on this document. I hereby assign and authorize payment directly to the providers at the office of Stephanie Cortes OD PA, the medical/vision benefits to which I am entitled under my insurance policy(s). I understand that I am financially responsible for charges not covered by this assignment. By receiving a service from Stephanie Cortes OD PA I am agreeing to pay for that service even if my insurance company denies payment. If I am not using insurance, I am responsible for all charges to this office.Patient Name* First Last Signature*HiddenDate MM slash DD slash YYYY CAPTCHAHiddenDate MM slash DD slash YYYY