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The information below is being offered voluntarily and solely for the provision of services at Shore Family Eyecare. If you would prefer to print out a copy, you can do so by clicking here.

Welcome to Our Office

  • If student

  • Last Eye Exam

  • Last Eyeglasses

  • Last Physical Exam

  • Medical History

  • Eye Health History

  • Insurance/Release of Information

  • 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.
  • Thank you for your confidence


For more information and up-to-date COVID-19 Procedures and Protocols, please click HERE. If you have a scheduled Telehealth appointment please click HERE.