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Hours & Location
Eye Care Services
Our Practice
- Our Doctors & Staff
- Community Outreach
Low Vision
- About Low Vision
- Low Vision Devices
Contact Lens Services
- Contact Lenses
Insurance Info
- What’s in Your Vision Insurance Plan
- FAQs of Vision Insurance Plans

Hours & Location
Eye Care Services
Our Practice
- Our Doctors & Staff
- Community Outreach
Low Vision
- About Low Vision
- Low Vision Devices
Contact Lens Services
- Contact Lenses
Insurance Info
- What’s in Your Vision Insurance Plan
- FAQs of Vision Insurance Plans

Hours & Location
Eye Care Services
Our Practice
- Our Doctors & Staff
- Community Outreach
Low Vision
- About Low Vision
- Low Vision Devices
Contact Lens Services
- Contact Lenses
Insurance Info
- What’s in Your Vision Insurance Plan
- FAQs of Vision Insurance Plans

Home » Contact Us » Welcome Form

Welcome Form

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

Name*
First Last
Date*
Month
Day
Year
Birthday*
Month
Day
Year
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*
Month
Day
Year
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.*
- I accept
This field is hidden when viewing the form
Are You at Risk for COVID-19
Please complete the questions below.
This field is hidden when viewing the form
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
This field is hidden when viewing the form
2. Have you been outside of New Jersey within the past 10 days?
- Yes
- No
This field is hidden when viewing the form
where?
This field is hidden when viewing the form
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
This field is hidden when viewing the form
4. Have you been fully vaccinated?
- Yes
- No
This field is hidden when viewing the form
If Yes When?
This field is hidden when viewing the form
Signature*
This field is hidden when viewing the form
Date*
Month
Day
Year
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
- I accept
Name
First Last
Relation to Patient
Signature
Name
First Last
Relation to Patient
Signature
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?
- Dietrich Opticians
- NJ Commission for the Blind
- Pediatrician
- Newspaper
- Internet/Website
- School Nurse/OT
- Eye Doctor
- Family
- Friend
- Insurance
Thank you for your confidence

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Shore Family Eyecare
161 Main Street
Manasquan, NJ 08736
Phone: 732-223-0202
https://www.lowvision-nj.com

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