Welcome to Davies Eye Center!

25 Years of Innovative Care

James A. Davies, MD, F.A.C.S

655 Laguna DriveCarlsbad, CA 92008760-729-7101

Our Mission Statement & Values

We are dedicated to providing quality Opthalmic medical services in a caring and professional atmosphere. The entire team at Davies Eye Center is committed to service, innovation, and quality care, while serving the needs of the community.

The Davies Eye Staff

Dr. James Davies, M.D. is the Medical Director of Davies Eye Center and Surgical Eye Care Center, located in Carlsbad. As a surgical pioneer, Dr. Davies has been

recognized as the authority in the field of cataract and refractive surgery with experience in a wide range of

procedures, such as Corneal and Anterior Segment Eye Surgery, Corneal Laser Refractive Surgery, LASIK, and

Making the Most of Your First Appointment

Davies Eye Center Patient Education

3) List all of your current Medications and Allergies

4) Complete the Review of Systems to mark any current or ongoing

5) Read, initial, and sign the Patient Agreement

GETTING TO KNOW YOU

1) Complete the New Patient Form

2) Complete the Patient Health History Form

symptoms you are experiencing

We'd like to help you get the most out of your first visit with Dr. Davies. Your time with him is valuable and we have a few suggestions to help you make the most of your visit.

To begin with, we ask that you complete the New Patient Information forms included in this Welcome Package before you come in to see Dr. Davies for your first visit. Please make sure you:

Please bring the completed forms and all insurance cards with you to your first visit. If you have any questions or would like assistance in completing any of these forms mentioned above, please call 760.729.7101 and we'd be glad to help.

Talk about your medications Talk about serious problems Don't be afraid to ask questions Review our Educational Videos on topics like Cataracts, Advanced Laser

Cataract Surgery, LASIK, Dry Eye Disease, or Refractive Surgeries directlyfrom our website, www.DaviesEye.com

Davies Eye Center offers many educational programs to the community, most of which are free of charge. Classes cover many topics and are generally open to anyone who wishes to attend, whether they are Davies Eye Center patients or not. Additionally, we offer a select number of courses for specific medical conditions that require a referral from your primary care provider.

Patient Last Name: First: Middle Initial: DOB:

Address: City: State: Zip:

SSN: Cell Phone: ( ) Home Phone: ( )

Gender: Male Female Marital Status: Single Married Separated Divorced Widowed

Race: Caucasian Asian American Indian/Alaska Native Black/African American

Hawaiian/Pacific Islander Hispanic/Latino Other Unknown

Preferred Language: Do you have a translator? Yes No

Emergency Contact: Phone: ( )

Relationship to Patient: Yes, you may discuss my medical information with this person.

EMAIL ADDRESS: May we send you information by email? Yes No

Primary Care Physician: Please send my exam notes to this Doctor

Phone: ( ) Fax: ( )

Optometrist: Please send my exam notes to this Doctor

Phone: ( ) Fax: ( )

Other Doctor: Please send my exam notes to this Doctor

Phone: ( ) Fax: ( )

Preferred Pharmacy Name:

Phone: ( ) Fax: ( )

Street Address: City:

How did you hear about us?

My Optometrist or other Doctor…Name?

Another Davies Eye Patient…Name?

Internet Search…Which website or What search words did you use?

Health Fair or Eye Screening…Location?

Newsletter or Magazine Ad…Which One?

Radio….Which Station?

Other…Please describe:

PATIENT SIGNATURE: DATE:

PHARMACY INFORMATION

REFERRAL SOURCES

AUTHORIZATION

I authorize DAVIES EYE CENTER to release my name in thanking the above named patient/friend/family member. I also authorize the release

of any medical information necessary to process all claims, including Medigap, and the release of payment of medical benefits to my physician.

AS A COURTESY TO ME, DAVIES EYE CENTER WILL BILL MY INSURANCE COMPANY. IF MY INSURANCE COMPANY HAS NOT PAID THE CLAIM

FOR WHATEVER REASON, WITHIN 60 DAYS OF TREATMENT, I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED. NOTE:

Medicare and other insurance providers typically do not cover reactive testing/procedures. You may be required to pay out of pocket for

these services.

NEW PATIENT FORM

PATIENT INFORMATION

DOCTOR INFORMATION

PATIENT NAME: DOB: Date:

Smoking Status? Current Smoker Occasional Smoker Former smoker Never smoked

Drink Alcohol? 3+ drinks per day 1-2 drinks per day Less than 1 drink per day None

Patient feels safe at home? Yes No If No, please explain: ________________________________________________________

Check ALL that apply:

Blindness Diabetes Hypertension

Cancer Glaucoma Macular Degeneration

Cataracts Heart Disease Retinal Detachment

Please check the following medical conditions that you CURRENTLY have:

Anxiety Depression Leukemia

Arthritis Diabetes - Insulin? Yes No Lung Cancer

Asthma End Stage Renal Disease Lymphoma

Atrial Fibrillation GERD Prostate Cancer

BPH (prostate) Hearing Loss Radiation Treatment

Bone Marrow Transplant Hepatitis Seizures

Breast Cancer Hypertension (High Blood Pressure) Stroke

Colon Cancer HIV/AIDS Hypothyroidism

COPD Hypercholesterolemia

Coronary Artery Disease Hyperthyroidism

None Apply

Check ALL that apply:

Appendix (Appendectomy) Gallbladder Skin

Bladder (Cystectomy) Heart Spleen

Breast: Lumpectomy R / L Joint Replacement: Knee R / L Uterus (Hysterectomy)

Mastectomy R / L Hip R / L Other (Please List):

Reduction R / L Kidney

Implants R / L Ovaries

Colon Prostate

None Apply

Check ALL that apply:

Allergic Conjunctivitis Dry Eyes Ocular Migraines

Blepharitis Glasses Retinal Detachment

Cataracts Glaucoma Retinal Tear

Contact Lenses Macular Degeneration Strabismus

Diabetic Retinopathy Narrow Angles Floaters

None Apply

Check ALL that apply:

Blepharoplasty Eye Muscle Glaucoma

Cataract Surgery Dates: LASIK/PRK: Retinal

Right Eye: _________ Right Eye: _________ Corneal Transplant

Left Eye: _________ Left Eye: _________ None Apply

PATIENT INITIALS:

PATIENT HEALTH HISTORY

SOCIAL HISTORY

FAMILY HISTORY

OCULAR HISTORY

OCULAR SURGERY

Other (Please List):

SURGICAL HISTORY

PATIENT NAME: DOB: Date:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

1.

2.

3.

4.

5.

PATIENT INITIALS:

PATIENT HEALTH HISTORY

MEDICATIONS

MEDICATION NAME DOSAGE FREQUENCY

ALLERGIES

MEDICATION/ANESTHESIA NAME REACTION

Please list ALL medications you are currently taking with their dosages and frequency. Include any vitamins and supplements.

Please list any and all medications you are allergic to and the reactions.

PATIENT NAME: DATE:

NAME SYSTEM YES NOPoor Vision Eyes m m

Eye Pain Eyes m m

Tearing Eyes m m

Redness Eyes m m

Jaw Pain Eyes m m

Scalp Tenderness Eyes m m

Amaurosis Fugax (Fleeting Blindness) Eyes m m

Loss of Vision Eyes m m

Fever Constitutional/Symptom m m

Chills Constitutional/Symptom m m

Weight Loss Constitutional/Symptom m m

Stuffy Nose ENT and Mouth m m

Ear Ache ENT and Mouth m m

Cough ENT and Mouth m m

Dry Mouth ENT and Mouth m m

High Blood Pressure Cardiovascular m m

Rapid Heart Beat Cardiovascular m m

Congestion Respiratory m m

Wheezing Respiratory m m

Shortness of Breath Respiratory m m

Upset Stomach Gastrointestinal m m

Diarrhea Gastrointestinal m m

Constipation Gastrointestinal m m

Burning on Urination Genitourinary m m

Urinary Frequency Genitourinary m m

Incontinence Genitourinary m m

Joint Pain Musculoskeletal m m

Stiffness Musculoskeletal m m

Arthritis Musculoskeletal m m

Rash Integumentary m m

Changing Moles Integumentary m m

Headache Neurological m m

Seizure Neurological m m

Stroke Neurological m m

Paralysis Neurological m m

Anxiety Psychiatric m m

Depression Psychiatric m m

Insomnia Psychiatric m m

Diabetes Endocrine m m

Thyroid Abnormalities Endocrine m m

Bleeding Hematologic/Lymphatic m m

Anemia Hematologic/Lymphatic m m

Allergies Allergic/Immunologic m m

Hay Fever Allergic/Immunologic m m

Hives Allergic/Immunologic m m

CONTINUED ON BACK

REVIEW OF SYSTEMS

Please respond based on current or ongoing symptoms you are experiencing.

PATIENT NAME: DATE:

ALERTS YES NOAllergy to Adhesive m m

Allergy to Lidocaine m m

Artifical Heart Valve m m

Artificial Joints within past 2 years m m

Blood Thinners m m

Defibrillator m m

Flomax m m

MRSA m m

Narrow Angles m m

Pacemaker m m

Premedication Prior to Procedures m m

Rapid Heart Beat with Epinephrine m m

Pregnancy or Planning a Pregnancy m m

Pseudoexfoliation Syndrome m m

Steroid Responder m m

West Africa: Travel or Contact m m

Ebola Risk: Fever > = 100.4 degrees (F)/38.0 degrees © m m

Ebola Risk: Resided or Traveled to Country with wide spread Ebola transimssion in the last 21 days m m

Ebola Risk: Contact with an Ebola patient without proper protective equipment in the last 21 days m m

Ebola Risk: Headaches, weakness, muscle pain, vomiting, diarrhea, abdominal pain, and/or hemorrhage m m

CONTINUED FROM FRONT

REVIEW OF SYSTEMS

Please respond based on current or ongoing symptoms you are experiencing.

INITIAL

1.

2.

3.

4.

5.

6.

Patient or Guardian* Name (Signature) Date

PATIENT AGREEMENT

I UNDERSTAND that I may request a copy of this assignment at any time. This assignment will remain in effect until revoked by

me in writing. A copy of this assignment is to be considered as a valid original.

(e.g., State Law, Court Order, Power of Attorney, etc.)

Patient or Guardian* Name (Print)

* If this authorization is signed by a Guardian or Personal Representative of the Patient, the Guardian or Personal Representative's authority

is based on:

RELEASE OF INFORMATION: Davies Eye Center/Surgical Eye Care Center may disclose all or any part of my medical record

and/or financial ledger to any entity which is or may be liable or under contract with Davies Eye Center/Surgical Eye Care

Center for reimbursement of services rendered, and other services related to my continued medical care including, but not

limited to: Insurance Carriers, Referring Physicians, Anesthesiologists and Transcription Agencies.

INSURANCE: I understand that Davies Eye Center/Surgical Eye Care Center will bill my insurance carrier as a courtesy to me. I

understand that it is MY RESPONSIBILITY to verify that Davies Eye Center, James A. Davies, MD, and/or Surgical Eye Care

Center is a contracted provider with my insurance carrier. If Davies Eye Center/Surgical Eye Care Center has no contract with

my insurance carrier, either expressed or implied, I understand that I am individually obligated to pay the full charges of all

services rendered to me by Davies Eye Center/Surgical Eye Care Center.

NON-COVERED SERVICES: I understand that Davies Eye Center/Surgical Eye Care Center contracts with health care service

plans for items and services which are 'covered' by the health care service plans. Accordingly, the undersigned accepts full

financial responsibility for all items or services which are determined by the health care service plans NOT to be covered.

Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient's

contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient; and

treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with Davies Eye

Center/Surgical Eye Care Center to obtain necessary health care service plan authorizations.

FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Davies Eye Center/Surgical Eye Care

Center, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Davies Eye

Center/Surgical Eye Care Center for payment. If an account is sent to a collection agency or attorney for collection, I agree to

pay collection expenses and reasonable attorney's fees as established by the court and not by a jury in any court action. I

understand and agree that if my account is delinquent, I may be charged a service fee. Any benefits of any type under any

policy of insurance insuring the patient or any other party liable to the patient is hereby assigned to Davies Eye Center/Surgical

Eye Care Center. If co-payments and/or deductibles are designated by my insurance carrier or health plan, I agree to pay them

to Davies Eye Center/Surgical Eye Care Center. However, it is understood that the undersigned and/or the patient are

primarily responsible for the payment of my bill.

PRIVACY PLAN: I agree that I have been given the opportunity to read and receive a copy of the Davies Eye Center/Surgical

Eye Care Center Notice of Privacy Practices. This practice provides this form to comply with the Health Insurance Portability

and Accountability Act of 1996 (HIPPAA).

Please initial before each item explaining your agreement with Davies Eye Center

REFRACTION FEE $43.00

The refraction is the portion of your eye exam that measures your ability to see an object at a specific

distance. From the exam chair you look through a phoropter toward an eye chart. The phoropter contains

lenses of different strengths and types that can be moved into view. Our technicians or doctors will ask you

which view is clearer as they place different lenses in front of the eye (“better one or two”). When you are able

to read the chart clearest, the technician or doctor will make notes of the lenses used. The process takes time

and patience due to the interaction required for the most accurate outcome. A refraction is not just for an

eyeglass prescription, although a new prescription is often the product of the refraction. The refraction is a

critical part of any examination. It helps the doctor determine whether your vision is reduced by a medical

disease (such as cataracts, macular degeneration, etc). It also helps the doctor follow the progression of

cataracts and other conditions.

Refraction has always been a NON-COVERED service under the MEDICARE program. Medicare does

differentiate between a “medical refraction” and refractions performed solely for the purpose of providing

glasses. OTHER INSURANCE plans may vary depending on your individual benefit coverage. In our

experience, unless you have vision benefit coverage on your insurance, it will probably NOT cover the cost of

the refraction. Our practice will submit this charge to your insurance carrier on your behalf, but please be

aware that if they do NOT pay for this portion of your exam, we will have to send a bill. If you KNOW your

insurance carrier will not pay the charge – we ask that you make payment at the time of service. We

recommend you check with your insurance provider PRIOR to your exam to see if you have coverage.

Patient Name: __________________________________

Signature: _____________________________________

Date: _________________________________________

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.

We understand that your medical information is personal to you, and we are committed to

protecting the information about you. As our patient, we create medical records about your

health, our care for you, and the services and/or items we provide to you. By law, we are

required to make sure that your protected heath information is kept private.

If you believe your privacy rights have been violated, you may file a complaint with the

Practice or with the Secretary of the Department of Health and Human Services. To file a

complaint with the Practice, contact our Office Manager. All complaints must be submitted in

writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you. These rights

include:

How will we use or disclose your information? Here are a few examples:

(For more detail please refer to the Notice of Privacy Practices)

PATIENT NOTIFICATION

SUMMARY OF PRIVACY PRACTICES

Date of last revision: 09-14-07

Effective date: Immediately

This information is made available upon request by a patient.

For medical treatment

To obtain payment for our services in emergency situations

For appointment & patient recall reminders

To run our Practice more efficiently and

To avert a serious threat to health or safety

For organ and tissue donation

For worker's compensation programs

In response to certain requests arising out of lawsuits or other disputes

For research

The right to inspect and copy

The right to amend

The right to an accounting of disclosures

The right to request restrictions

The right to a paper copy of this notice

The right to request confidentialcommunications

How to find us…

655 Laguna DriveCarlsbad, CA 92008760-729-7101

From the I-5 Freeway

Exit Las Flores and head West

Make a LEFT on Jefferson Street

Make a RIGHT on Laguna Drive

Davies Eye Center is on the left hand side just past Madison Street

Laguna Dr

Jeffe

rson

StJe

fferso

n St

Las Flores Dr

Street View

Street View