Patient Information and Registration
Enter the information of the person seeing the doctor.
Red asterisks * indicates required fields.
Enter physician information of the person seeing the doctor.
Parent / Legal Guardian Information
Please enter information for at least one parent or legal guardian
Parent 1 Information
Parent 2 Information
Legal Guardian's Information
Person Accompanying Child on Appointment
Please enter information of the person accompanying the child on their appointment
Person Responsible for Account
Please enter information of the person responsible for payment
Medical and Family History
Please enter information regarding the patient seeing the doctor
History of Eye Problems: Has the patient had any of the following?
Recent Ocular Symptoms: Has the patient had any of the following?
Review of Medical Symptoms (Medical History): Does the patient currently have or have a history of any of the following? Give details on "yes" reponses.
Allergies: Does the patient have any allergies?
Surgery or Medications
Related Family History
Have any of the patient's relatives had any of the following? Please indicate the relation to the patient.
Please read and confirm
Our office is not a participating provider with health insurance plans and we do not file health insurance claims but we will do our best to guide you.
The receipt we provide at your visit will have a medical procedure and diagnosis code to be used for your insurance reimbursement submission. If you have out-of-network coverage, you can submit this receipt for reimbursement through the vision and/or medical portion of your insurance.
We're happy to help if you have any questions or require any additional assistance.
Terms and Conditions
I certify the above information is correct to the best of my knowledge. I understand that I am financially responsible for this patient's account. I understand that payment is due at time of service. I also acknowledge that a cancellation fee of $25 will be charged if this office is not notified 24 hours prior to cancellation of an appointment, except in the case of an emergency.
I understand that the information that I have given is correct and complete to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my or my child's medical status.
I authorize staff of Pediatric Optometry and Vision Care to perform the necessary in-office examinations that my child (or myself in an adult patient) may need.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor the agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Our Office provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I have verbally reviewed the medical information above with the parent/guardian and/or patient named herein.
Submit To Our Office
Please hit submit to complete. You will receive an email confirmation.
Once you're done completing all information, please hit the "Submit to our Office" button below to forward your information to us in preparation for your appointment. You will receive an email confirming your submission.
If you have any questions, please ask, email or call our office at 212.410.1291.