Wada Optometry
936 S. Brookhurst St., Anaheim, CA 92804

Patient Record Optometry

Personal Details

How did you hear about us?

Do you wear glasses?

How old are the present glasses?

Previous glasses type:

Are you interested in purchasing new glasses today?

Interested in:

Do you wear contact lenses?

Do you currently wear?

How often do you discard your contact lenses?

Do you use Monovision Contact Lens?

Do you currently use a multifocal Contact Lens?

Contact Lens Fitting Policy

Please acknowledge and accept the information provided below:

  • The contact lens fitting is an additional charge to your regular eye exam and includes the of the fitting, lens design, verification, dispensing, training (if needed), evaluation, and follow up visits for a period of one year.
  • Follow up visits are generally scheduled in 1 week, and 6 months. The doctor may vary these appointments depending on the patient's contact lens experiences or observation of any potential difficulties. There are no additional charges for these visits, and you will be given a solution care kit upon leaving our office.
  • Contact lens prescriptions are valid for 1 year. Once the prescription has expired, If you would like to keep ordering contact lenses, you will need to return to renew the contact lens prescription.
  • The doctor must make sure that your eyes are healthy for continued use of contact lenses. Complications such as Corneal Edema, Neovascularization of the Cornea, Conjunctivitis, Dry Eyes, Blepharitis, Meibomium Gland dysfunction are all reasons why your contact lens prescription may not be renewed. The contact lens fitting fee is charged annually in addition to the eye exam fee.
  • At the time of your fitting, the doctor will re-evaluate the fit of the existing lenses and decide if any changes in parameters or lens material is needed.
  • Sometimes Solutions can the source of many contacts lens complications as well. Recently, many of the contact lens manufacturers continue to improve the comfort, vision and wettability of their products. Our doctors will discuss any recent lenses that have come out on the market. Contact lenses can be changed in base curve, thickness, disposability, diameter, edge design, or water content (material) to improve patient comfort and vision.
  • Contact lenses are medical devices and are governed by the FDA. The potential loss of vision, related to contact lenses requires these lenses to be fitted by a doctor. Under state law, doctors are to provide eye glass and contact lens prescriptions upon completion of an eye exam and/or contact lens fitting. However, our office policy for the release of contact lens prescription is as follows:
    • We will release the contact lens prescription after a thorough follow up visit to confirm that you are having no issues with vision or comfort.
    • We try to give you the very best price on contact lenses. If requested, we will price match if you can show us the current advertisement or receipt. No verbal price matching can be done.

I acknowledged I have read the information above and would like to be fitted for Contact lenses.

Contact Lens Prescription Signed Acknowledgment Form

Included below is important information to review prior to receiving your contact lens prescription.
The Centers for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free—especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment."
The CDC recommends the following for contact lens wearers:
  • Schedule a visit with your eye doctor at least once a year.
  • Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision.
  • Understand that eye infections that go untreated can lead to eye damage or even blindness.

The Food and Drug Administration (FDA) indicates:
  • "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional."

Symptoms of Eye Infection include:
  • Irritated, red eyes
  • Worsening pain in or around the eyes—even after contact lens removal
  • Light sensitivity
  • Sudden blurry vision
  • Unusually watery eyes or discharge4

Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting.
Patient Name
13 Jun 2024

Reason for visit today

Would you be interested in receiving information about Lasik Surgery?

Last Eye Examination

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Chief Complaint

Previous Ocular Diagnosis

Family Ocular History

Previous Ocular Surgeries

Year of last Medical exam visit

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Do you currently smoke or use chewing tobacco?

Do you use recreational drugs?

My current Medical Conditions

Family Medical History

I agree and acknowledge this HIPAA compliance form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
  •  The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  • The practice may condition receipt of treatment upon execution of this consent.

Dilation Consent Form

Dilation is an essential part of a complete eye examination. Dilation will make the pupils of the eyes larger allowing the doctor to visualize the back of the eye looking for any potential problems or diseases. Dilation involves placing drops into the eye. There is a slight burn initially, but dissipates in a matter of seconds.

  • The dilation will make reading things up close difficult, and make lights seem brighter than usual. This will last for 3-5 hours, although it can last longer in some people. Most people will be able to drive once their eyes are dilated, as long as they have sunglasses (which we can provide if you didn’t bring any). However, if you feel uncomfortable driving, or have never driven with your eyes dilated, it may be best to have a driver. Please note there is no additional charge for having your eyes dilated.
  • It is highly recommended to have your eyes dilated if:
    * You are new to our office.
    * You are diabetic.
    * You are over the age of 45.
    * You have glasses or contact lens prescription over -4.00.
    * Have been previously diagnosed with a condition in the back of the eye that needs yearly monitoring.
    If you do not fit in the above categories, it is still recommended to have your eyes dilated at least every two years.
  • If refusing to have your eyes dilated, you understand that you are assuming all risks associated with failure to diagnose eye conditions due to lack of information, which may have been provided by this test.

I would elect to have the scan done today. I understand there is an additional co pay of $15.00 for this procedure

OCT (Optical Coherence Tomographer) - is a device that uses light waves to create highly detailed images which allow the doctor to see beneath the surface of your retina.

What is an iWellness Exam?
It's a quick, non-invasive scan that images critical areas of the back of your eye.

Why is iWellness recommended?
Can help detect early signs of various diseases like macular degeneration, glaucoma, diabetic retinopathy and others eye conditions.

Who should get an iWellness Exam?
We recommend an iWellness as part of an annual check up for ages 25 and over Diabetes, hypertension, patients taking Plaquinel
Family history of ocular disease

The scans below are from patients who were screened with iWellness and had no symptoms.

Fluid within the retina creating an area of separation

Macular drusen - hard deposits within the retina typically associated with macular degeneration. Having this information helps with formulating a plan for future observation and treatment.

Vitreous detachment - represented by the faint line, it's a frequent occurrence as the eye ages.


Fluid within the retina creating an area of separation


Macular drusen - hard deposits within the retina typically associated with macular degeneration. Having this information helps with formulating a plan for future observation and treatment.


Vitreous detachment - represented by the faint line, it's a frequent occurrence as the eye ages.

I would like to have the Optomap retinal exam and I understand the co-pay for this procedure will be $35.00

As we are all dealing with the effects of Covid-19, our practice is committed to assuring your safety and well-being during your visit with us today. As part of our new health and safety protocols, the Optomap is now required by our doctors because it is the safest way to check the health of your eyes at a safe distance.

This screening procedure can monitor for retinal complications including macular degeneration, glaucoma, and retinal holes or detachments. It will also detect problems unrelated to the eye that may show early signs in the retina such as hypertension, cancer/tumors, auto-immune disorders, and others.

The Optomap® Retinal Exam:
Is as fast as taking a picture.

DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, potentially eliminating a 30-minute wait and avoiding side effects such as blurry vision and light sensitivity.
Will be saved in your file enabling your doctor to make important comparisons during your annual eye exam.

We are committed to providing you with safe and thorough care. Due to COVID-19 this technology is now our standard of care. The co-pay for this procedure is $35.00


Diabetic Breakthrough!

Non-Invasive Opthalmic test for the detection and management of Diabetes.

Diabetic Diabetic1
I would like to have the scan today. I understand there is an additional co pay of $15.00. This test is intended for a diabetic screening for patients who are pre-diabetic, who have family history of Diabetes and previously diagnosed.  This test is for patients between the ages of 20- 70 years who have not had cataract surgery.

This specialized fluorescence microscope is used to detect autofluorescence of the crystalline lens which is caused by accumulation of advanced glycation products or sugar.  It is shown that higher levels of sugar in the eye  may be an indicator for diabetes.

A quick 6 second test  will yield accurate results.  The patient places their eye in from of the machine and fixates on a red blinking LED light.  When the operator has aligned the patient’s eye with the fixation  target, the  test will begin.  A blue light will shine on the eye and the machine will harmlessly scan the crystalline lens in the eye and will generate a digital image.  The results are given instantaneously and the ClearPath DS-120 is FDA approved for use in the US.

Your height and weight is needed for the calculation

COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form

Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.

On March 16th, 2020, The Centres for Disease Control and Prevention (CDC) issued the following Public Health Reminder:

Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several weeks. The following actions can preserve staff, personal protective equipment, and patient care supplies: ensure staff and patient safety, and expand available hospital capacity during the COVID-19 pandemic:

- Delay all elective ambulatory provider visits
- Reschedule elective and non-urgent admissions
- Delay inpatient and outpatient elective surgical and procedural cases
- Postpone routine dental and eyecare visits

I have read the above states Public Health Reminder and have answered the health questions above honestly and to the best of my knowledge. I understand that the doctors and staff are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent.

By signing this form below, I agree that I will not hold any of the doctors or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge the doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.
13 Jun 2024

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