• Kings Medical Eye Care P.C.

    Kings Medical Eye Care P.C.

    KERATO New York

  • Dr. Alexander Movshovich, MD, PHD

    www.kerato.com info@kerato.com
  • Date of birth*
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  • Gender*
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  • The following information is used for research purposes only:

  • Primary Language (please indicate one)*
  • Race (please indicate one)*
  • Ethnicity (please indicate one)*
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  • REFERRAL INFORMATION:

  • How did you hear about us?
  • Date*
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  • Kings Medical Eye Care P.C.

    Kings Medical Eye Care P.C.

    Dr. Alexander Movshovich, MD

  • Patient Medical History Record

  • Date of birth*
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  • Gender*

  • Please answer the following questions about your medical status and history:

  • 1. Have you ever been treated for any medical conditions (e.g. diabetes, high blood pressure, arthritis, pulmonary disease, bowel disorder, neurological disorder, rheumatologic disorder or malignancy etc.?)*
  • 2. Have you ever had any eye disease or injury (e.g. glaucoma, cataract, lazy eye, or retinal detachment?)*
  • 3. Have you ever had any ocular treatment (surgery, laser, eye drops, or patching)?*
  • 4. Do you wear, or have you ever wore, eyeglasses or contact lenses?*
  • 5. Have you ever been hospitalized?*
  • 6. Do you take any prescription medications, including eye drops?*
  • 7. Do you take any over-the-counter medications, vitamins or herbal supplements?*
  • 8. Do you have any drug or food allergies?*

  • Review of Systems

  • Rows

  • Family and Social History

  • Do any medical or eye disease run in your family (e.g. diabetes, high blood pressure, glaucoma, cataract, macular degeneration)*
  • Do you smoke?*
  • Do you drink alcohol?*
  • Date*
     / /

  • Media Release Form

  • I grant permission to Kings Medical Eye Care PC, hereinafter known as the Kerato NYC and its affiliates to use my image (photographs and/or video) for use in Media publications including, but not limited to Instagram, Facebook, Twitter, YouTube Channel, TikTok, KERATO NYC and its affiliates website, magazines (for advertisement purposes) etc. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or video recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area and unrestricted time.

  • I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.      

  • I am 21 years of age or older, and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release.      

  • I DO NOT give Kings Medical Eye Care PC permission to use my images/video in any Media publications.

  • Date*
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