(661) 775-1860

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(661) 775-1860

Home New Patient Forms Adult Online Questionnaire

Adult Online Questionnaire

Please carefully complete our questionnaire. This form does not need to be printed, once submitted, we should receive it on our end. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your visual system related to your specific needs.

48 Hour Cancellation Policy

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill other patient’s scheduling needs and keeps the clinic operating at is most efficient level. Due to our 60-minute exams missed appointments are a significant inconvenience to your doctor, the clinic and other patients.

This policy is in place out of respect for our doctors and our clients. Cancellations with less than 48 hours notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot and leave a 60-minute hole in the doctor’s schedule.

Please provide our office with 48-hour notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 48-hour notice to change a scheduled appointment will be responsible for a $75.00 service charge. This charge cannot be billed to insurance and must be paid before scheduling your next appointment.
We reserve your one-hour appointment time just for you. We do not double-book our patients so that we may provide optimum treatment outcomes for all our patients. 48-hour notice allows us to offer that time to a wait-listed patient.

NOTE: You will never be charged for a cancellation if it is made more than 48 hours in advance of your scheduled appointment time.

Thank you for providing our office and our patients with this courtesy.

Sincerely,

Drs. Garbus & Benosa, and the Family Vision Care Staff

General Information

First Name

Last Name

Gender Male Female

Birth Date

Street Address (with apartment #)

City

State

Zip Code

Phone Number #1

Type

Phone Number #2

Type

Vision Care Insurance

Name of Subscriber

Last 4 Number of Social Security of Subscriber

Birth Date of Subscriber

Please check one of the following:

Appointment with: Dr. Carl Garbus Dr. Danielle Benosa

Appointment Date

Patient History

Medical History

Medications/Dosage and Reason

Allergies

Surgical History

Vision History

Loss of Vision Yes No

Explain

Blurred Vision Yes No

Explain

Distorted Vision/Halos Yes No

Explain

Loss of Side Vision Yes No

Explain

Dryness Yes No

Explain

Mucous Discharge Yes No

Explain

Redness Yes No

Explain

Sandy or Gritty Feeling Yes No

Explain

Itching Yes No

Explain

Burning Yes No

Explain

Foreign Body Sensation Yes No

Explain

Excess Tearing/Watering Yes No

Explain

Glare/Light Sensitivity Yes No

Explain

Eye Pain, Tired Eyes, or Soreness Yes No

Explain

Chronic Infection of Eye or Lid Yes No

Explain

Sties or Chalazion Yes No

Explain

Flashes/Floaters in Vision Yes No

Explain

Tired Eyes Yes No

Explain

Date of Last Eye Exam

Name of Doctor

Which was prescribed last eye exam? Glasses Contact Lenses Nothing

Would you like information regarding refractive surgery (Lasik)? Yes No

Contact Lens Policy: If you are requesting a contact lens prescription, our office provides a full service program – evaluation, fitting, and follow-up. Our office does not release the contact lens prescription until you have been successfully evaluated and fitted.

Review of Systems

Do you use tobacco products? Yes No

If yes, what type, how much, and how long?

Do you consume alcohol? Yes No

If yes, what type, how much, and how long?

Do you currently, or have you ever had any problems in the following areas? If you do, please explain.

Integumentary (Skin) Yes No

Explain

Neurological

Headaches Yes No

Explain

Migraines Yes No

Explain

Seizures Yes No

Explain

Ears, Nose, Mouth, and Throat

Allergies Yes No

Explain

Hay Fever Yes No

Explain

Sinus Congestion Yes No

Explain

Runny Nose Yes No

Explain

Post-Nasal Drip Yes No

Explain

Chronic Cough Yes No

Explain

Dry Throat/Mouth Yes No

Explain

Cold Sores Yes No

Explain

Respiratory

Asthma Yes No

Explain

Chronic Bronchitis Yes No

Explain

Emphysema Yes No

Explain

Tuberculosis Yes No

Explain

Vascular

Diabetes Yes No

Explain

Heart Pain Yes No

Explain

High Blood Pressure Yes No

Explain

Vascular Disease Yes No

Explain

Genitourinary

Genitals Yes No

Explain

Kidney Yes No

Explain

Bladder Yes No

Explain

Venereal Disease Yes No

Explain Yes No

Syphilis Yes No

Explain

Gonorrhea Yes No

Explain

Bones, Joints, and Muscles

Rheumatoid Arthritis Yes No

Explain

Muscle Pain Yes No

Explain

Joint Pain Yes No

Explain

Lymphatic and Hematologic

Anemia Yes No

Explain

Bleeding Problems Yes No

Explain

HIV Yes No

Explain

Endocrine (Thyroid/Other Glands) Yes No

Explain

Psychiatric Yes No

Explain

Cancer Yes No

Explain

Family History

If anyone in the family (grandparents, uncles, aunts, cousins, mother, father, and/or siblings) has any of the following conditions, please indicate who and whether it is a maternal or paternal family member. If not applicable, please leave it blank.

Amblyopia

Arthritis

Blindness

Brain Tumor

Cancer

Cataracts

Cornea Problems

Corneal Transplant

Crossed/Lazy Eye

Detached Retina

Diabetes

Epilepsy/Seizures

Glaucoma

Heart Problems

High Blood Pressure

Keratoconus

Kidney Problems

Learning Disability

Macular Degeneration

Multiple Sclerosis

Stroke

Tuberculosis

Thyroid Condition

Traumatic Brain Injury

History of Dizziness or Imbalance

Photos/Dilation

48 Hour Cancellation Policy I have read, understand, and agree to abide by the policy above.

Please do not submit any Protected Health Information (PHI).

Location

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Family Vision Care Optometry INC.

Contact Information

Phone: (661) 775-1860

Fax: (661) 775-9627

Email: customercare@fvcoptometry.net

Address

28089 Smyth Dr
Valencia, CA 91355

Hours of Operation

Monday

09:00 am - 06:00 pm

Tuesday

09:00 am - 06:00 pm

Wednesday

09:00 am - 06:00 pm

Thursday

09:00 am - 06:00 pm

Friday

09:00 am - 06:00 pm

Saturday

Closed

Sunday

Closed

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