Online Patient Form

Click here to return to the previous website.

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:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN (Last 4) Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Same?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Vision

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 (Last 4):
Employer/School:

Primary Medical

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 (Last 4):
Employer/School:

Secondary Vision

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 (Last 4):
Employer/School:

Secondary Medical

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 (Last 4):
Employer/School:

Medical History

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

VISUAL HISTORY


Reason For Today's Visit:
Chief Complaint:
Eye History (Injuries, Surgeries, etc):
I Currently Wear Glasses: Full-Time Part-Time If Part - Time, How Often / When?
I Currently Wear Contacts: Full-Time Part-Time If Part-Time, How Often/When?
Are Your Lenses Comfortable? Yes No
Current Brand:
What do you not like about your contact lenses?
Solution used: What is your replacement schedule?
How old is your current pair?
Please list all eyedrops you use (OTC and Rx): How Often Used?


Do You Have History Of The Following?

Condition Yes No Condition Yes No
Blindness Glaucoma
Eye Turn (Strabismus) Cataracts
Lasy Eye (Amblyopia) Macular Degeneration
Keratoconus Retinal Detachment


Are You Currently Experiencing Any Of The Following?

Condition Yes No Condition Yes No Condition Yes No Condition Yes No
Headaches Halos Around Lights Yes Itch Feel Sandy/Gritty
Blurred Vision Bothered By Light/Sun Yes Burn Flashing Lights
Double Vision Frequent Styes Eyes Tear Floaters
Yes "Hurt" or "Tired" Yes Frequently Red Eyes Feel Dry

Describe any eye injuries:
List any eye surgeries:
Other eye disease or condition


How many hours a day do you use a computer? Describe any visual symptoms from computer use:

MEDICAL HISTORY/REVIEW OF SYSTEMS



Physician's Name: Last Physician's Visit:
Physician's Address: Physician's Phone Number:


List All Medications You Are Currently Taking (Including Any OTC/Vitamins): List Any Medications You Are Allergic To:


Are You Pregnant Or Nursing? Yes No If Yes, What Is The Due/Birth Date?


Do You Have, Or Ever Had, Any CHRONIC Problems In The Following Areas?

Condition Yes No Condition Yes No Condition Yes No
Migraines Arthritis High Blood Pressure
Multiple Sclerosis Allergies/Hay Fever Stroke
Diabetes Asthma Anemia
Thyroid Problems Emphysema Cancer


FAMILY HISTORY


Any History of the Following in any Family Members (Parents, Grandparents, Siblings, Children)?

Family History Unknown/Adopted

Condition Yes No Relationship to Patient
Poor Vision
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
Other Inherited Disease
If yes, what disease?


Submit Form / Patient Signatures


CONTACT LENSES

A contact lens exam is not included in the annual eye exam and eye health exam. Contact lenses are medical devices and require an exam to obtain or renew your prescription. This exam includes computerized topography and mapping of the cornea as well as an evaluation of which lenses will fit and provide optimal comfort, vision, and eye health. During this exam, the Doctor will assess the contact lens fi t, check parameters and look for any medical issues arising from contact lens w ear. The fee ranges from $75 and up depending on what type of lenses you are fit to wear. This fee is not normally covered under insurance but there are some insurance companies that will pay whole or part of the fee or offer discounts towards it. Please ask any staff person and they will provide more information regarding any portion of this statement including possible costs and insurance coverage.

Do You Wish To Have A Contact Lens Exam Today?

DIGITAL RETINAL IMAGING

To examine the health of your eyes, the Doctor will need to examine the structure of the eye through DIGITAL RETINAL IMAGING or DILATION.
After reviewing the following information, please indicate your choice below:

As part of your routine comprehensive exam, Dr. Moscovitz recommends Digital Retinal Imaging which involves capturing a high-resolution digital image of the interior of your eye through Retinal Photography and/or Optical Coherence Tomography{OCT). Both procedures (4 scans in total) are the gold standard for preventative care and disease management.

The Daytona OPTOS provides a 200 degree field of view of the retina and can help identify the presence of retinal lesions, such as holes, tears, or detachments, which can be present without any signs or symptoms, and can cause permanent vision loss. This device offers a second screening called auto fluorescence, which allows the Doctor to find many diseases (such as macular degeneration, nerve drusen, diabetic retinopathy) BEFORE they appear in a normal dilated exam. The Zeiss OCT is another non-invasive im aging test that uses light waves to take cross-sectional pictures of your retina, the light-sensitive tissue lining the back of the eye. These measurements help with early detection of macular and opticnerve conditions again BEFORE they appear in a normal dilated exam.

Retinal Imaging is NOT covered by insurance. The fee is $39.

You may decline the Retinal Imaging, and choose dilation at no extra charge. Dilation will result in blurred vision for reading and light sensitivity that may last anywhere from 3-24 hours.
PLEASE INDICATE YOUR CHOICE:

Do you agree to have Retinal Imaging performed instead of dilation:

(Under certain circumstances, the Doctor may recommend BOTH dilation and Retinal Imaging.)

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY POLICY:

Information about your treatment and care, including payment for care, is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under this law, NewVision Eyecare may not disclose any protected information, except as permitted by the federal laws referenced in the Privacy Policy.

By signing below, I acknowledge that I am aware of my rights to privacy and will receive a copy of the Notice of Privacy Practices upon requested. A copy will be provided in the office immediately upon arrival.

Signature Of Patient, Parent, Or Guardian (please initial): Date:

INSURANCE ASSIGNMENT AND CONSENT FOR TREATMENT

I hereby authorize NewVision Eyecare to bill my Vision/Medical insurance company and for payments to be made directly to NewVision Eyecare. I understand that any insurance benefit is a QUOTE and NOT A GUARANTEE of payment by the insurance company. I am responsible for any remaining balance. If there is no vision or medical insurance coverage, payment is due at the time of service. If the parent or guardian of a minor, I understand I am responsible for all unpaid balances. The guardian who brings in a child, or whom the child lives with, is ultimately responsible for all unpaid balances.

Additionally, I hereby authorize treatment by Dr. Kerry Moscovitz, or an associate, to administer such medication and perform diagnostic testing and therapeutic procedures as may be necessary for proper eye care.

Signature Of Patient, Parent, Or Guardian (please initial): Date: