Name*

First Last

Date*

Birthday*

Address*

Street Address Address Line 2 City State Zip

Primary Phone*

Work Phone

Cell Phone

Email

SS#

Occupation

Gender*

Male
Female

Marital Status*

Single
Married
Other

Spouse's Name

First Last

Race

Ethnicity

If student

What grade?

What school?

Parent's Name

First Last

Last Eye Exam

How many years ago?

Who were you examined by?

Last Eyeglasses

How many years ago?

Last Physical Exam

How many years ago?

Who were you examined by?

Medical History

Do you take any medications or vitamins?*

Yes
No

Please list:

Are you allergic to any medications?*

Yes
No

Please list:

Do you or a family member have (sugar) Diabetes?*

Yes
No

Do you have Arthritis?*

Yes
No

Do you or a family member have High Blood Pressure?*

Yes
No

Do you have Thyroid Dysfunction?*

Yes
No

Do you or a family member have Heart Troubles?*

Yes
No

Do you have any other medical conditions?*

Yes
No

Please list:

Have you or a family member had cancer?*

Yes
No

Do you currently smoke?*

Yes
No

Eye Health History

Do you or a family member have Glaucoma?*

Yes
No

Do you or a family member have Cataracts?*

Yes
No

Do you or a family member have Macular Degeneration?*

Yes
No

Have you ever had eye surgery?*

Yes
No

Do you or a family member have a lazy eye or eye turn?*

Yes
No

Do you have problems with dry eye or tearing?*

Yes
No

Do you wear or are you interested in contact lenses?*

Yes
No

Do you suffer from eye allergies?*

Yes
No

What is the reason for today’s visit?

Insurance/Release of Information

Do you have routine vision insurance?*

Yes
No

Please list:

What Insurance Company?

ID#

Do you have medical insurance?*

Yes
No

Please list:

What Insurance Company?

ID#

Primary Insured Name*

First Last

Primary Insured DOB*

Address

Check if different address

The staff at Shore Family Eyecare will be happy to submit to your insurance for your visit. It is your responsibility to know if your insurance covers the type of office procedures performed and whether referrals are necessary.

I am responsible for all fees, referrals, co-pays, deductibles and non-covered procedures and devices provided. I authorize Shore Family Eyecare to submit to my insurance and assign the benefits to be directly paid to the doctors of Shore Family Eyecare when applicable.

I understand that Shore Family Eyecare is fully compliant with HIPAA regulations and privacy issues. I request my professional records/reports only to be released to Shore Family Eyecare when necessary and to release my records to other doctors/professionals who may provide care for me in the future.

Are You at Risk for COVID-19

Please complete the questions below.

1. Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?

Yes
No

2. Have you been outside of New Jersey within the past 10 days?

Yes
No

where?

3. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?

Yes
No

4. Have you been fully vaccinated?

Yes
No

If Yes When?

Signature*

Date*

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures and financial information. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. I authorize Shore Family Eye Care to release my records and any information requested to the following individuals

Name

First Last

Relation to Patient

Name

First Last

Relation to Patient

Authorization Regarding Messages (please check all that apply)

I authorize you to leave a detailed message on my home or cell number regarding appointments
I authorize you to leave a detailed message on my home or cell number regarding medical treatment, care, test results or financial information
I authorize you to leave a message with anyone who answers the phone
Messages may only be left with

Messages may only be left with

How did you hear about Shore Family Eyecare?

Thank you for your confidence

Welcome Form

Welcome to Our Office

If student

Last Eye Exam

Last Eyeglasses

Last Physical Exam

Medical History

Eye Health History

Insurance/Release of Information

Are You at Risk for COVID-19

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