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Patient Record

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  • 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.
    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.
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  • If you wish to view and/or download a copy of our Notice of Privacy Practices, please click here

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  • PATIENT’S MEDICAL HISTORY QUESTIONNAIRE

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  • Patient’s Ocular History

  • (Please check yes for any conditions that are present in your or your family’s history)
  • 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
  • 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.
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