Patient Forms

Are you a new patient? Fill in one of our patient forms before you come in to expedite your appointment!

 

List of Accepted Insurance Providers

3rd Party Providers

  • Medicare
  • AARP
  • Aetna Medicare
  • Bluecross/Blueshield
  • Excellus (but no medicaid or childhealth plus plans)
  • United Health Care/The Empire Plan (not the Community Plan)
  • Lifetime Benefit Solutions
  • Veteran's Choice Program

Additional Insurance Providers

  • VSP - Vision Service Plan
  • Eye Med
  • Davis Vision

 

Date *
Date
Name *
Name
If Child (Guardian Name):
If Child (Guardian Name):
Date of Birth
Date of Birth
Telephone
Telephone
Cell Phone
Cell Phone
Work Phone
Work Phone
Patient History Information
A medical complaint includes blurry vision, watery, itchy eyes, flashes, floaters, vision loss, pain, light sensitivity, pressure.
Please Check Boxes for all that pertain
Medications
Doctor's Phone Number:
Doctor's Phone Number:
Date of last exam:
Date of last exam:
Date of last eye exam:
Date of last eye exam:
Lifestyle
*IMPORTANT*
NYS Board of Optometry has established that a comprehensive eye examination for a new patient includes a Dilated Exam. This procedure involves putting one or more drops in each eye thtat will dilate the pupils. The doctor will then study the internal structures of the eye to ensure proper health. The drops will cause the eyes to be light sensitive and vision will be blurred, especially when reading near, for 4-6 hours. Some patients the effects will be longer. Driving may be difficult and should be done with extreme caution.
HIPAA PRIVACY (Acknowledgement of Receipt of Privacy Notice)
By checking AGREE to this acknowledgement of Receipt of Notice of Privacy Practices (the "Notice"); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that the Location may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with my regarding vision care services provided by the Location (for example, mailings of exam reminders or information about services/products provided by the Location). I can be assured that this Location does not sell my personal health of any kind to a third party for such party's own use. I authorize the Location to submit my vision benefit claim to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received from the Location.
*
Date Acknowledgement of Receipt of Privacy Notice Was Received *
Date Acknowledgement of Receipt of Privacy Notice Was Received