Eye Exam Online Forms

Only fill out these forms if you already have an appointment.
If you do not have an appointment, please call our office at the phone number above to schedule.

Your data will only be submitted after you see the "Thank You" page.
Please submit one form per patient who will be seen.

Cataract Surgery Refractive Surgery (LASIK or PRK) Muscle Surgery for Strabismus Glaucoma Surgery or Laser Retinal Detachment Surgery or Laser Foreign Body Removal Injections for Macular Degeneration Laser or Injections for Diabetic Retinopathy Corneal Crosslinking Other (Please Explain Below):

Please provide the name of your Authorized Representative below: Name (Leave blank if you will not be designating an authorized representative)

An authorized representative is a person to whom our office can release written prescription, contact lenses, glasses, or any reports that you have requested.

Without a designated authorized representative, any of the above may be released only to the patient themselves, or to parents if the patient is under 18 years of age.

The guardian listed in the "under 18" section is the default authorized representative for any patient under 18 years old unless otherwise listed above.

Signatures and Agreements

Insurance Agreement

I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to Dr. Gary J. Lake, OD, PC on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in item 9 of the HCFA-1500 claim form or electronically submited claim), my signature authorizes release of the above medical information to the insurer or agency shown and authorizes my doctor to act as my agent above.

Financial Agreement

I acknowledge that services furnished to me may not be covered completely by my insurance carrier. I have advised the office of Dr. Gary Lake to proceed, and I assume responsibility for payment to them if my insurance carrier does not pay for certain visits or procedures.

HIPAA Agreement

I acknowledge that I have read the Notice of Privacy (HIPAA) practices.
I acknowledge that a copy is available to read in office upon request.

Enter your full name below to indicate your agreement to the above statements.

Name
Date

Adult and Pediatric Eyecare

200 Midway Park Drive, Suite 1
Middletown, NY 10940
845-343-6919

Basic Information

Fill out the following if the patient is under 18 years old:

Address

Contact Information

More Information About You

Some Medical Questions

Select all that apply to your medical history:

Medications and Allergies

Select all that apply to your Family Medical History:

Some information about your eyes:

Do you experience any of the following symptoms?

Select all that apply to your eye history:

Select all procedures that you have had to your eyes.

Select all that apply to your Family Ocular History.

Authorized Representative

Signatures and Agreements

Insurance Agreement

Financial Agreement

HIPAA Agreement

Enter your full name below to indicate your agreement to the above statements.

Please click the button below to submit all entered data. Your form will not be complete until you see the page indicating "Thanks" for submitting your information.