Financial Policy Release of Information Privacy Practices Acknowledgement
The Vision Development Team extends the courtesy of
filling out a medical insurance claim form for you to submit
to your insurance company for reimbursement to you.
I understand that I will be required to pay for services at the time rendered.
I authorize Alexandar Andrich, OD, FCOVD to release any
information required by my insurance company.
I have received the Notice of Privacy Practices and I have
been provided an opportunity to review it.
(Guardian signature required if patient is under 18)
VERY IMPORTANT! NEW PATIENTS ONLY
Please silence cell phones prior to
entering the Doctor’s exam room Thank you!
Most recent medical examination:
Young Child History
Have you ever received:
Previous eye examination:
Members of the family who have had visual attention and why:
Does your child report any of the following:
For each question please check “yes” or “no” and then check
each of the subsequent statements, which describe your child.
Your responses will probably be most accurate if you read all
of the descriptions under the question before selecting “yes” or
“no”. If you have additional of different descriptions, please
include them under “other”.
1. Is your child particularly sensitive to touch?
2. Does your child have trouble with gross motor or posture?
3.Does your child particularly enjoy fast-moving or spinning
equipment at the playground or at home, seeming to be less
dizzy than the others or not dizzy at all?
4. Does your child show particular caution in approaching
activities involving fast movement or movement of the body
5. Do you feel your child has already established a definite
hand preference or dominance?
6. Can your child easily orient his/her body effectively for
dressing activities, such as putting arms in sleeves, putting
fingers in mittens or putting toes in socks?
7. Does your child spontaneously engage in active physical
games involving running, jumping, and use of large play
8. Does your child spontaneously seek out activities requiring
manipulation of small objects?
9. Does your child spontaneously choose to do activities
involving the use of “tools”, such as crayons, pencils, markers,
10. Have you ever had any concerns regarding your child’s
speech and language skills?
11. Have you ever had any concerns regarding your child’s
hearing, either in general or in conjunction with ear infections?
12. Is your child particularly sensitive to noise (for example puts
hands over ears when others are not bothered by sounds)?
13. Do you feel that your child has an adequate attention span
for things which he/she enjoys?
14. Do you feel that your child tends to be restless or “fidgety”
during times when quiet concentration is required?
Family and Home
Please sign below to give us permission to release information
about your child to the above sources.