New Patient Form

Demographics

Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Medical History

PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below.


Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: Recent Tetanus Shot:

Notes:

Primary Care Physician: Phone: Fax: Last Visit:

Reason For Visit: List any Vitamins you take:

FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)




Occupation: Hobbies:

Smoking Status: Type: How Long:

Alcohol: Type: How Long:

Illegal Drugs: Type: How Long: STD:

PATIENT OCULAR HISTORY
Please select if you have had any of the following:   Additional Issues: 

Please select your current Eye Meds:            Additional Medications: 

Dosage: 

Last Eye Doctor: Last Eye Exam:
 
FAMILY OCULAR HISTORY

Glaucoma: Crossed / Lazy: Retinal Detach:

Macular Degeneration:  Cataracts: 

Primary Vision Correction:   Planning to get new glasses?  Back up specs?

Type of CLs worn in past:   Contact Brand: 

Wear Time: Cleaner: Disposal:

NOTES:

Preferred Language:  Ethnicity:   Race: 
 

REVIEW OF SYSTEMS - DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux


Consent Form


Contact Lens Information: Each individual insurance; it may, or may not cover a contact lens exam. Each year annually a new exam is required for the health of your eye. Please refer to your benefits for further information. A contact lens fitting fee may apply. Please ask before services.
Please check one below:
I accept a contact lens examination
I would like to reschedule an exam
I decline a contact lens exam
Responsibility of Patient
Please be aware of what your insurance does and does not cover. You may be responsible for some or your entire bill depending on your insurance company's policy. I understand that I am responsible for any unpaid amount not covered by insurance.
I acknowledge that I have read the HIPPA Privacy Notice posted at Freehold Family Eyecare 3333 Route 9 North, Freehold, NJ 07728
Signature of patient: 
Date: 
Dilation is a special test which consistes of using drops to dilate the pupils (make pupils larger). This procedure allows the doctor to examine the part of the inside of your eye called peripheral retina, which cannot be seen without dilating your pupils. It is important to evaluate the peripheral retina for the presence of tumors, retinal tears, or detachments, and certain types of degeration: which do not have any symptoms and can cause a loss of vision if not detected. For patients who are diabetic, have high blood pressure, wear a strong eyeglasses prescription, or have cataracts; it is even more important for you to have this test performed. Many insurances other than union plans cover this procedure.
Please select one below
I accept Dilation
I would like to reschedule Dilation
I have elected not to have Dilation done and release Dr. Sclafani from any liability as a result of not having this test.
Automatic Visual Field Plotter is a procedure where a sophisticated computerized visual field plotter actually tests your retina. This becomes especially important for people with general health problems such as diabetes, high blood pressure, or glaucoma. It serves as an excellent reference point from which your doctor can make future comparisons. This test is painless and can be performed in conjunction with the dilation, or as a separate procedure. Many insurances other than union plans cover this procedure.
Please select one below
I accept Automatic Visual Field Plotter
I decline Automatic Visual Field Plotter
Retinal Photograph is a scan that shows either a healthy eye or detects current or potential diseases. It provides the doctor with a more detailed view than she can get by other means. The fee for the retinal photograph is $39.00.
Please select one below
I accept the Retinal Photograph
I decline the Retinal Photograph
       Date: 
Signature: 

Submit Data

After Completing All Forms Submit Data on Final Tab