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VALLEY OPTOMETRY EYECARE
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    All information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
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  • 3
    All information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
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  • 4
    Please tell us more about yourself so that we can assess your visual demands
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  • 5
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  • 6
    • No
    • Yes
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    • Yes
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  • 7
    • No
    • Yes
    • Yes, I wear contacts
    • No, I do not use contacts
    • No, but I want to try contacts
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  • 8
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    • Yes
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    • Yes
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  • 9
    • Yes
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  • 10
    Please choose all that apply
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  • 11
    Please choose all that apply
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  • 12
    • No
    • Yes
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  • 13
    Please check all that apply
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  • 14
    • Insurance List
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    • Referred by someone
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  • 15
    By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Notice of Privacy Practices and agree to its terms.
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  • 16
    The FDA categorizes contact lenses as a medical device and requires an annual contact lens evaluation to renew any contact lens prescription. By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Contact Lens Policy and agree to its terms.
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  • 17
    To provide you with the highest level of care, we require OPTOS digital retinal imaging to all routine eye examinations. The Optos technology allows our doctors to better monitor the health of your eyes for any potential retinal issues. Further, it will reduce your time inside the office and provide proper distance from the doctor. The copay has been reduced to $25. By clicking, you acknowledge that you have reviewed a copy of the office's Advance Digital Eye Exam Policy and agree to its terms.
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  • 18
    The information entered is true to the best of my knowledge. I authorize any insurance benefits to be paid directly to the physician and acknowledge that I am financially responsible for any balance not paid by my insurance company. I authorize Valley Optometry Eyecare Center or insurance company to release any information required to process my claims. I have reviewed the policies & warranties understand that all professional exam fees and sales of contact lenses and optical goods are non-refundable and due at time of services rendered.
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