Please choose from the menu options or
type in your own text. Thank you!
Eye History
Contact Lens Wearers only:
Family Eye History
Does anyone in your family have any of these eye
conditions?
Medical History
Patient & Family Medical History
Does anyone in your family or you have any of these medical
conditions?
Review Of Systems
Social History
Patient Signatures / Submit Data
Dilated Fundus Examination
Involves drops to dilate the pupil. Pupil dilation
allows the doctor to examine the entire retina for any signs of disease including
breaks, holes, hemorrhages, tumors or degenerations for which treatment may be
necessary. During routine exams without dilating drops, the pupil size limits the
doctor's view to only the central 30% of the retina. The following diagrams show the
area of retina visible with and without pupil dilation.
The drops take 15 minutes to work and cause the pupil to remain enlarged for about 4
hours. During this time, you will be sensitive to light, and you may have blurry near
vision. Most people can still drive afterwards, although distance vision may be slightly
blurred. We will provide you with disposable sunglasses if you did not bring your own.
Digital Retinal Imaging
Allows the doctor to get a more magnified view of the internal health of your eye.
• Digital retinal photography uses a specialized camera to take high resolution
images of the back of the eye (retina).
• Optical Coherence tomography (OCT) uses light waves to capture
high-definition 3D views beneath the retina often where signs of eye disease first
appear.
• With the combination of these two tests, images can be tracked and compared
for subtle changes over time.
In refusing dilation, you assume all risks associated with failure to detect eye
conditions due to lack of information that may have been provided by this test. As such,
timely and effective treatment may not be possible resulting in vision loss.
Please click on the blue underlined links below, read carefully and sign your acceptance
by
entering your First and Last Name in the boxes below.
Acknowledgment of Notice of Privacy Practices
-View HIPAA
Patient Privacy Policy Form-
The law requires that Princeton Family Eye Care makes every effort to inform you of your
rights
related to your personal health information. By signing below, I acknowledge that I was
given the
opportunity to read, have read or had explained to me Princeton Family Eye Care Notice
of Privacy
Practice prior to any services offered.
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
If you are signing as a personal representative of the patient, please indicate your
relationship.
If you are signing for a minor, you attest that you have legal authority to make medical
decisions
for the minor.
Financial Responsibility Policy
-View
Financial
Responsibility Policy Form-
We accept both vision and medical insurance which are very different in terms of the
services they cover.
Vision insurance (e.g. VSP, Spectera) is a wellness benefit designed to reduce
the cost of routine annual eye exams and prescription glasses and contact lenses.
Medical insurance (e.g. BCBS, Aetna, Medicare) is designed to help cover the cost
of a medical problem, including one that affects your eyes. Examples include dry or
itchy eyes, red eyes, eye pain, floaters, headaches and diabetes. Some medical insurance
plans ALSO cover routine eye exams for patients who need a prescription for glasses or
contact lenses and are otherwise healthy.
There is often no way to know prior to the exam, which type of insurance will be
appropriate with which to file your claim, as this is based on the reason for your visit
and the results of your exam. Insurance carriers set these rules and our office is
required to follow them. We offer direct billing and in the event we are out of network
with your insurance plan, we provide an itemized receipt so you may file with your
carrier for reimbursement. Coverage will be verified before your exam, however, we are
not responsible for discrepancies once the claim is filed. If you have any questions,
please let us know before your appointment.
By signing below, I acknowledge that I have read this information and understand
completely.
Contact Lens Exam Agreement
(Please only sign if you are scheduled or thinking of having a
contact lens eye exam)
-View Contact
Lens Agreement-
I have read the contact lens patient care agreement and fitting fee. I understand the
fitting procedure and that full payment is expected at the time a contact lens fitting
is performed.
** By entering my First and Last name, I understand, agree
and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my
handwritten signature.