PATIENT INFORMATION FORM What are you interested in? (Required) Name (Required)
(Required) Sex (Required) Marital Status Preferred Contact Any restriction for contacting you? Is it okay to call you at work? How did you hear about us? (Required) Address
INSURANCE INFORMATION Relationship to the insured? Untitled VISION INSURANCE Relationship to the insured List any medications you’re currently taking (Rx and over-the-counter): Do you have allergies to any medications? (Required) Have you ever had a blood transfusion? PLEASE CHECK BOX IF THE ANSWER IS YES TO ITEMS BELOW: FAMILY HISTORY: Maternal
Please check box if the answer is yes for maternal
FAMILY HISTORY: Paternal
Please check box if the answer is yes for paternal
PLEASE CHECK BOX IF YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS: Cardiovascular Endocrine Stomach / intestinal Ocular Surface Disease Neurologic / Psychiatric Hematologic Respiratory Musculoskeletal Ear / Nose / Throat Cancer Skin Problem Additional Allergy Symptoms SOCIAL HISTORY
Please answer the questions below
Do you drink alcohol? Do you currently smoke? Are you a former smoker? COVID-19 RISK INFORMED CONSENT
I (patient name) understand that I am opting for an eye exam/treatment/procedure/surgery that may not be urgent and may not be medically necessary.
I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Dr. Lillie Mosaddegh and all the staff at Mosaddegh Eye Institute is closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Dr. Lillie Mosaddegh and all the staff at Mosaddegh Eye Institute to proceed with the same.
I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.
I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care Treatment, possible need for intubation/ventilator support, short-term or longterm intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or hospital.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself.
I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery. Financial Policy
In order to provide the best possible care at a reasonable fee, we request your cooperation with our financial policy.
Payments may be made in cash, by check or by Visa, Mastercard,, American Express or Dicover.
The cost of your visit depends upon the complexity of the problem and length of your appointment.
Refraction checks the optical state of the eyes to determine whether glasses are needed or a change in glasses is necessary, or to determine if a change in vision is due to medical pathology rather than a refraction change.
Refraction is performed to all patients requesting to have a new glasses prescription.
If this exam is not a covered benefit through your insurance it is an out of pocket fee of $65 on the
date of service at no exception.
Also not included in your exam fee are
Contact Lens Services. These may include, but are not limited to: first time fitting, re-fit, or yearly prescription refill evaluation. Prices vary depending on the services and type of contact lenses prescribed, please ask the front desk or the doctor for this information.
Please bring a copy of your insurance card and a claim form (if required).
co-payment is due at time of service.
Cancellation without Notice
If you do not show for a scheduled appointment and have not given at least 24 hours notice by voicemail or by alerting our staff personally, you will be given a warning the first time. The second time this occurs, you will be charged a $70 fee to help compensate us for the time on our schedule, which we allotted for your visit.
Returned check fee - $20.00
Copying of records - 50¢ a page plus rush or postage fees as listed on records release form.
Extra reports - $25 (this includes DMV forms)
We are happy to discuss any questions relating to your insurance.
I have read and understood the above information.
Financial Policy - Signature of Responsible Financial Party: (Required) ADVANCED BENEFICIARY NOTICE
I authorize Lillie A. Mosaddegh, M.D. to provide care and treatment to me and
hereby request to pay Lillie A. Mosaddegh, M.D. all benefits accruing to me
under my Medical Plan. I hereby certify that I am eligible with the insurance plan
mentioned above and that I have chosen Lillie A. Mosaddegh, M.D. as my
I understand that if I am not eligible for the above mentioned insurance, or do
not have insurance; I am responsible for all charges for services rendered.
And that it is my own responsibility to verify with my insurance company
before receiving treatment that it is a covered benefit and that Lillie A.
Mosaddegh, M.D is an in-network provider. I understand I am financially responsible to the physician for all charges