New Patient Form

1040 Hempstead Tpke

Franklin Square, NY 11010

516-354-4242

New Patient Form

Name: ________________________________________________________________________________________________________________________

Last

First

MI

Address: ______________________________________________________________________________________________________________________

City

State

Zip

Home #: _____________________________ Work/Cell #: _____________________________ Email: __________________________________________

DOB _________/________/____________ Age ________ Sex _______ Occupation ______________________________________________________

Medical Insurance ______________________________________________ Member ID / SSN_______________________________________________

Vision Insurance ________________________________________________ Vision ID/SSN__________________________________________________

If the patient is a dependent, name of parent/subscriber responsible for the account.

Name: _____________________________________________________________ Relationship to patient: ______________________________________

DOB of Subscriber __________/ ____________/ ______________________

Date of last eye exam: _______/______/ ______________ By whom? ____________________________________________________________________

Are you having problems seeing:

In the distance?

q Y

q N

Up close/reading

q Y

q N

At computers?

q Y

q N

If you wear contacts, what brand/type do you use?

RGP q Soft q Brand: ____________________________________________________

H a v e y o u o r y o u r f a m i l y m e m b e r s e v e r b e e n d i a g n o s e d w i t h a n y o f t h e f o l l o w i n g c o n d i t i o n s ?

Yourself

Family

Yourself

Family

High blood pressure

Cancer (type___________________)

q Y q N q Y q N

q Y q N q Y q N

Diabetes

Glaucoma

q Y q N q Y q N

q Y q N q Y q N

Thyroid disorder

Macular degeneration (ARMD)

q Y q N q Y q N

q Y q N q Y q N

Heart disease

Lazy eye (Amblyopia)

q Y q N q Y q N

q Y q N q Y q N

High cholesterol

Eye turn (Strabismus)

q Y q N q Y q N

q Y q N q Y q N

Do you currently take any medications? q Y q N

If yes, please list

__________________________________________________

Are you allergic to any medication?

If yes, which ones?

__________________________________________________

q Y q N

Any other known allergies?

If yes, to what?

__________________________________________________

q Y q N

Have you had eye surgery?

If yes, what kind and when? __________________________________________________

q Y q N

INFORMATION ON MEDICAL INSURANCE PLANS

Medical insurance will only pay for medically related eye examinations which require a medical diagnosis. If the main reason for your visit is for a routine/yearly eye exam

or contact lens check-up, your insurance plan may not pay and the patient is responsible for this fee.

Most insurance plans DO NOT pay for refractions (the part of the exam that checks for eyeglass prescriptions). The patient is responsible for this part of the fee.

Most medical insurance carriers and union plans do not pay for a contact lens evaluation or a contact lens fitting. The patient is responsible for this part of the fee.

Please initial _____

I authorize the release of medical information necessary to provide the most beneficial/complete visual examination. I understand that I am financially responsible for all

charges whether or not paid for by insurance. Payment is due at the time services are rendered. Thank you!

_____________________________________________________

Signature of patient or responsible party