New Patient Forms – Plainsboro Step 1 of 3 - Patient Information 33% Patient InformationName Dr.Mr.Mrs.Ms.Miss Prefix First Last Marital Status: Married Single Divorced Widowed Gender Male Female Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security # (Last four digits) E-Mail Telephone (H)Telephone (W)Telephone (C)Employment Status: Full-time Part-time Unemployed Student Name of Employer: Preferred Language English Spanish French Japanese Declined to Specify Race American Indian or Alaskan Native Asian Black or African American Hispanic Native Hawaiian or Other Pacific Islander White Declined to Specify Ethnicity Hispanic or Latino Not Hispanic or Latino Native Hawaiian or Other Pacific Islander Declined to Specify Communication Preference E-mail Postal Telephone Responsible PartyName of Person Responsible for the Account First Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneSocial Security # (Last four digits) Relation to Patient Currently a patient in our office? Yes No Employer E-Mail Primary Insurance InformationInsurance Company ID # Group # Name of Insured: Relation to Insured: Employment Status: Full-time Part-time Unemployed Student Name of Employer: Additional Insurance InformationInsurance Company ID # Group # Name of Insured: Relation to Insured: Employment Status: Full-time Part-time Unemployed Student Name of Employer: The preceding information is true to the best of my knowledge and I request any applicable payments of insurance be made on my behalf to Allied Vision Services for any services rendered. I authorize any holder of medical information about me to release to the insurance company and its agents any information needed to determine these benefits or benefits for related services. I understand that I am responsible for any referrals needed for services rendered here (if in a managed care insurance program), and for any fees not covered by my insurance company owed to Allied Vision Services. Patient / Parent SignatureDate MM slash DD slash YYYY Acknowledgement of ReceiptI acknowledge that I have received a copy of Allied Vision Services of Plainsboro’s Notice of Privacy Practices. Privacy PolicyPatient / Parent SignatureDate MM slash DD slash YYYY Medical HistoryVision plans cover “routine” eye exams. Some medical plans will only cover the visit if there is a medical reason for the visit, such as loss of vision, eye redness, eye discomfort, dry eyes, glaucoma, cataracts, floating spots, etc. If we are able to use your medical insurance to cover the visit, you will have to pay both the specialist copay as listed on your insurance card and the refraction fee (refraction is the part of the exam that determines your eyeglass prescription) We will help as much as possible to determine coverage, but ultimately, you are responsible for referrals and fees not covered or applied to your deductible. For current contact lens wearers or those who want to be fit for contact lenses, there is an additional fee (other than the eye exam fee) for the evaluation and measurements necessary to determine the health, safety and proper lens selection for the eyes. This includes any wearing instructions, starter solutions/kits, and any follow-up visits to complete the fitting/evaluation, as determined by the doctor. These measurements and lens needs can change and will need to be re-evaluated over time.Please initial that you understand the above statements:Are you interested in purchasing new glasses today? Yes No Do you currently wear contact lenses? Yes No Are you interested in contact lenses? Yes No Are you interested in Laser Vision Correction? Yes No REASON for VISIT: How can we help you today? Please tell us below the main eye/vision problem that you are having:Are there any associated symptoms? Does anything alleviate the symptoms? Review of Systems:Do you or any family member have or ever had the following? (Please check if “Yes”)YouFamilyYou and FamilyAllergiesArthritisAsthmaAutoimmune DisorderCancerDiabetesGastrointestinal DiseasePsychiatric DisordersThyroid DiseaseGlaucomaLazy EyeHeadacheHeart DiseaseHigh Blood PressureHigh Cholesterol Lung ProblemsNeurological ProblemsGenito/UrinarySkin ConditionsEye/Head Injury Eye SurgeryOther Eye DiseaseAre you pregnant? Yes No Are you nursing? Yes No Please list any medications you are taking now: Are you a: Current Smoker Former Smoker Never Smoked Alcohol use: Socially Daily Use Never Any drug allergies? No Yes Optos ConsentDuring a comprehensive eye exam our doctors need to evaluate the overall health of your eye. With the optomap® Retinal Exam, they can screen for retinal complications including macular degeneration, glaucoma, and retinal holes or detachments. This screening procedure can also detect problems unrelated to the eye that may show signs in the retina such as diabetes, hypertension, cancer/tumors, auto-immune disorders, and others, earlier than possible with traditional methods. For more information about the importance of Optomap, please Click here The optomap® Retinal Exam: ✔ Is as fast as taking a picture. It also will reduce time and contact in the exam room. ✔ DOES NOT REQUIRE DILATING DROPS. You may not need to be dilated today, avoiding side effects such as blurry vision and light sensitivity. ✔ Saved in your file enabling our doctors to make important comparisons during your annual eye exam. There is a $35.00 fee for the optomap® Retinal Exam.Please make your selection* I understand that the optomap retinal exam will be performed today and do not have any questions. I do NOT want to have this test done. Name First Last SignatureDate MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
