New Patient Paperwork
Patient Name
*
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Gender
*
Please Select
Male
Female
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is it okay to call/text You?
*
Yes
No
Occupation:
If a student, what grade?
Please upload a photo of your valid driver’s license or government-issued ID:
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Choose a file
Cancel
of
Do you have insurance?
*
Please Select
Yes, I have insurance
No, I will self-pay
Please upload a clear photo of the FRONT of your insurance card:
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Choose a file
Cancel
of
Please upload a clear photo of the BACK of your insurance card:
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Drag and drop files here
Choose a file
Cancel
of
Has anyone is your household been a patient before?
Please Select
Yes
No
How did you hear about our office?
Please Select
Google
Facebook
Website
Other
Who can we thank for referring you to us?
Hours spent on electronic devices (computer, iPad, iPhone)
What was your last eye exam?
-
Month
-
Day
Year
Date
Do you wear glasses?
Yes
No
Do you wear contact lenses?
Yes
No
Do you need a contact lens exam?
Yes
No
Primary Care Physician:
Last physical:
-
Month
-
Day
Year
Date
Do you have any allergies to medication?
If yes, list allergies.
Are you able to make financial decisions for yourself?
Please Select
Yes
No
Select all health issues, if any:
High Blood Pressure
Diabetes
Choesterol
Thyroid
Cancer
Pregnant
Other
None
Have you had any major surgeries? If yes, please list:
Please list all current medications:
Your pharmacy name/location:
HIPPA COMPLIANCE ACKNOWLEDWe respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of private practices. We protect your health information and what rights you have regarding it. If we need to disclose your health information outside of our office we will ask for your written permission. If you would like a copy of this policy please feel free to ask for one.
*
Please Select
I Acknowledge that I have reviewed this policy and that I was offered a copy of "Notice of Privacy Practices"
Signature
*
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Explanation of Medical vs Vision Insurance Coverage
I understand the paragraph above, and I authorized Precision Eye Care of NJ to file my insurance bythe above guidelines. I am aware that I am responsible for any co-payments, co-insurance ordeductibles set in accordance with my insurance provider. I am also responsible for any treatment ortesting that my insurance provider does not cover.
Print Patient Name:
*
First Name
Last Name
Signature:
*
Today's Date:
*
-
Month
-
Day
Year
Date
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Cancellation Policy
I certify that I have read and fully understand the above statements and consentfully and voluntarily to its contents. A photocopy of this consent shall beconsidered as valid as original.
Print Patient Name:
*
First Name
Last Name
Signature
*
Today's Date:
*
-
Month
-
Day
Year
Date
If you're not the Patient, please identify your relationship to the patient:
Parent
Legal Guardian
Power of Attorney
Send
Send
Should be Empty: