Online Patient Form

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


Title First Last MI Suffix Nickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
Email
Birthday
Sex
Employer / School Name How Did You Hear About Our Office?

Primary Insurance

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

Secondary Insurance

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

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past:
Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Patient Signatures / Submit Form

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

My Authorization: I authorize Jonathan D Wolfe OD, P.C. to use or disclose my health information. I authorize the release of any medical or other information necessary to process insurance claims. The purpose of this authorization is at my request. This authorization ends when I am no longer a patient of Jonathan D Wolfe OD, P.C. The above party may also disclose this health information to the following recipient:

My Rights: I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization fits purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I may receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

For patients receiving Contact Lens services:

I understand that I am entitled to a physical copy of my contact lens prescription, and that a copy of my contact lens prescription will be provided to me at the conclusion of today's exam. I understand that some insurances do not cover contact lens evaluations, and that this fee should be discussed prior to the exam.

COVID-19 Health Screening:

I affirm that I have not experienced any of the common symptoms of COVID-19 in the past 2 weeks. I, or anyone in my household has not tested positive for COVID-19, or been in close contact with any known COVID-positive individuals in the past 2 weeks. If I have recently traveled out of state, I have followed all applicable quarantine protocols put forward by New York state.

Patient Signature: Date: