Intake Form Step 1 of 5 - Step 1 20% Appointment Check-InName First Last PhoneEmail Date MM slash DD slash YYYY Appointment time : Hours Minutes Your Primary Care Physician In order to provide continuity of care, we ask that you provide us with your Primary Care Physician’s (PCP) information for your records. Your PCP Their Phone Acknowledgement Of Receipt I acknowledge that I received a copy of Dr. Dr. Matt Buchanan O.D., Notice of Privacy Practices (Your Information, Your Rights, Our Responsibilities - HIPAA). Print Patient Name Date MM slash DD slash YYYY Signature Optomap RequirementConsent I understand that RidgeView Optometry performs the Optomap Retinal Imaging on all patients for $39 during all Annual / Comprehensive Eye Exams. This ensures you receive the best quality of care. If I cannot afford the $39 or have any questions or concerns, I will inform RidgeView Optometry staff. Treatment Consent Form I, (the patient), consent to receive treatment from Ridgeview Optometry. Consent* I am confirming that I currently do NOT feel sick for today's visit. *Consent* I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 or awaiting COVID-19 test results in the past 5 days.*Consent* If I have any changes to my address, insurance, medical conditions, medications or allergies I will fill out the Patient History Form OR if I am a new patient, I will fill out the Patient History Form.*Consent* I understand that while masks are optional, RidgeView Optometry prefers that masks to be worn over the nose and mouth while in the office and exam rooms.*Patient Name Patient/Guardian Signature