New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr.

Address: City: State/ZipCode NJ NY

Home Phone: Work Phone: Other Phone: Alerts: Cell Phone: Preferred Contact Method: Home Phone Work Phone Cell Phone Other Phone Text Message Email SSN Email Birthday Occupation Sex Male Female Employment Status Employed Full-Time Student Part-Time Student Marital Status Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Employer/School Name Primary Eye Doctor No Doctor Assigned Dr. Beja, Edward Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr.

Address

City	State	ZipCode
	NJ NY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP AARP MEDICARE AARP EYEMED AETNA BC/BS BC/BS FEDERAL EMPLOY BC/BS HORIZON DIRECT CIGNA EYEMED EYEMED DISCOUNT KALUSTYAN CORP. CHN MEDICARE NONE OXFORD SPECTERA UNITED HEALTHCARE VSP VSP DISCOUNT
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP AARP MEDICARE AARP EYEMED AETNA BC/BS BC/BS FEDERAL EMPLOY BC/BS HORIZON DIRECT CIGNA EYEMED EYEMED DISCOUNT KALUSTYAN CORP. CHN MEDICARE NONE OXFORD SPECTERA UNITED HEALTHCARE VSP VSP DISCOUNT
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Primary

Insurance Information

Insurance Name:	None AARP AARP MEDICARE AARP EYEMED AETNA BC/BS BC/BS FEDERAL EMPLOY BC/BS HORIZON DIRECT CIGNA EYEMED EYEMED DISCOUNT KALUSTYAN CORP. CHN MEDICARE NONE OXFORD SPECTERA UNITED HEALTHCARE VSP VSP DISCOUNT
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Secondary

Insurance Information

Insurance Name:	None AARP AARP MEDICARE AARP EYEMED AETNA BC/BS BC/BS FEDERAL EMPLOY BC/BS HORIZON DIRECT CIGNA EYEMED EYEMED DISCOUNT KALUSTYAN CORP. CHN MEDICARE NONE OXFORD SPECTERA UNITED HEALTHCARE VSP VSP DISCOUNT
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Chief Complaint

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

Chief Complaint

Reason for Visit:

Annual Exam Annual CL Exam Blurry vision Burning Cataract Follow Up Cataract Post Op CL Follow Up Diabetic eye exam Distance vision blurry Dryness Floaters or spots Follow Up GLC Follow Up Headaches LASIK Follow Up Near vision blurry Pain Retinal Follow Up * * * * * * * * * * * * * * * * * Broke eyeglasses Double vision Eyelids swollen Failed driver screening Flashes of lights Fluctuating vision Focusing difficulty Foreign body sensation Intermediate vision blurry Itching No visual complaints Red eyes Scratchy Twitching of eyelids Wants to be fitted for contact lenses Watery Eyes * * * * * * * * * * * * * * * * * * OU OD OS * * * * * * * * * * * * * * * * * * started gradually started suddenly * * * * * * * * * * * * * * * * * * seems the same getting worse getting better Other

Secondary Complaints:

Notes:

Contact Lens History

Total Wear Time:	1 hour 10 hours 11 hours 12 hours 13 hours 14 hours 15 hours 16 hours 17 hours 18 hours Overnight 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 hours 9 hours Other	Max Wear Time:	2 Hours 3 Hours 4 Hours 5 Hours 6 Hours 7 Hours 8 Hours 9 Hours 10 Hours 11 hours 12 Hours 13 hours 14 Hours 15 hours 16 hours 17 hours 18 hours Overnight 1 week 1 month 2 weeks 18 hours Other	Replacement Schedule:	2 weeks 3 weeks daily monthly weekly yearly when irritated when torn Other
Solutions:	Aquify BioTrue Boston ClearCare Complete Costco/Kirkland Generic None Optifree Optifree Express Optifree Pure Moist Optimum Extra Pure Moist Renu Revitalens Unknown Lobob Other

Notes:

Miscellaneous

Occupation
Employer
Referred by:

History Form

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

Patient Medical History

Ref'd by
Case History / Reason for Visit:
Last eye exam?	Last eye examination was 1 year ago. Last eye examination was 2 years ago Last eye examination was 3 years ago Last eye examination was over 3 years ago Other
Does patient wear eyeglasses?	I do not know how old my prescription is. Eyeglasses are 1 year old Eyeglasses are 2 years old Eyeglasses are over 3 years old Other
Does patient wear contact lenses?	Wearing contacts for 1-5 years Wearing contacts over 5 years Other

CL WT

2 Hours 3 Hours 4 Hours 5 Hours 6 Hours 7 Hours 8 Hours 9 Hours 10 Hours 12 Hours 14 Hours 15+ hours Overnight 1 week 2 weeks 1 month Other

CL Replace Sched:

2 weeks monthly daily weekly yearly When irritated When torn Never Other

Solutions:

Aquify BioTrue Boston ClearCare Complete Costco/Kirkland Generic None Optifree Optifree Express Optifree Pure Moist Optimum Extra Pure Moist Renu Revitalens Unknown Lobob Other

Ocular History

	You	Mom	Dad	Siblings
Glaucoma:
ARMD:
Retinal Problems:
Cataracts:
Lazy Eye/Eye Turns In:

REVIEW OF OCULAR SYSTEM:	FAMILY OCULAR HISTORY:

Previous eye surgeries:

OTC Eye Drops:

Other

Ocular Meds:
None Acular Alamast Alaway Alocril Alomide Alrex antibiotic topical unspecified bacitracin Besivance Bepreve Bleph 10 Blephamide Blink Ciloxan compliance with glaucoma meds Cromolon Cromolyn NA 4% Decadron Durezol Elestat erythromycin Flarex FML FML Forte Liquifilm FML Liquifilm FML UNG gentamicin Genteal ketorolac 0.4% lacrilube Livostin Lotemax maxidex Maxitrol muro128 ung NaCl ointment Naphcon A neosporin not compliant with ocular medications Ocufen Ocuflox ofloxacin 0.3% Pataday Patanol polysporin polytrim Pred Forte pred G. prednisolone acetate 1% Prolensa Refresh Refresh Ointment Restasis rewetting drops steroid unspecified Systane tears natural ointment tetracycline Theratears Tobradex tobramycin Tobrex Travatan vasocidin Vexol Vigamox vira A Viroptic Visine Voltaren Xalatan Zaditor Zylet Zyrtec eyedorps Other	Sig:	1gtt OU qPM 1 drop both eyes right eye left eye once a day twice a day three (3) times a day four (4) times a day Other
None Acular Alamast Alaway Alocril Alomide Alrex antibiotic topical unspecified bacitracin Besivance Bepreve Bleph 10 Blephamide Blink Ciloxan compliance with glaucoma meds Cromolon Cromolyn NA 4% Decadron Durezol Elestat erythromycin Flarex FML FML Forte Liquifilm FML Liquifilm FML UNG gentamicin Genteal ketorolac 0.4% lacrilube Livostin Lotemax maxidex Maxitrol muro128 ung NaCl ointment Naphcon A neosporin not compliant with ocular medications Ocufen Ocuflox ofloxacin 0.3% Pataday Patanol polysporin polytrim Pred Forte pred G. prednisolone acetate 1% Prolensa Refresh Refresh Ointment Restasis rewetting drops steroid unspecified Systane tears natural ointment tetracycline Theratears Tobradex tobramycin Tobrex Travatan vasocidin Vexol Vigamox vira A Viroptic Visine Voltaren Xalatan Zaditor Zylet Zyrtec eyedorps Other	Sig:	1gtt OU qPM 1 drop both eyes right eye left eye once a day twice a day three (3) times a day four (4) times a day Other
None Acular Alamast Alaway Alocril Alomide Alrex antibiotic topical unspecified bacitracin Besivance Bepreve Bleph 10 Blephamide Blink Ciloxan compliance with glaucoma meds Cromolon Cromolyn NA 4% Decadron Durezol Elestat erythromycin Flarex FML FML Forte Liquifilm FML Liquifilm FML UNG gentamicin Genteal ketorolac 0.4% lacrilube Livostin Lotemax maxidex Maxitrol muro128 ung NaCl ointment Naphcon A neosporin not compliant with ocular medications Ocufen Ocuflox ofloxacin 0.3% Pataday Patanol polysporin polytrim Pred Forte pred G. prednisolone acetate 1% Prolensa Refresh Refresh Ointment Restasis rewetting drops steroid unspecified Systane tears natural ointment tetracycline Theratears Tobradex tobramycin Tobrex Travatan vasocidin Vexol Vigamox vira A Viroptic Visine Voltaren Xalatan Zaditor Zylet Zyrtec eyedorps Other	Sig:	1gtt OU qPM 1 drop both eyes right eye left eye once a day twice a day three (3) times a day four (4) times a day Other

GLC Meds:
None Alphagan P Azopt Betagan Betoptic-S .25% Betoptic .5% Combigan Cosopt Latanoprost Lumigan Pilo Gel Propine Timoptic .25% Timoptic .5% Tobradex Trusopt Xalatan Zioptan Other	Sig:	1gtt OU qPM 1 drop both eyes right eye left eye once a day twice a day three (3) times a day four (4) times a day Other
None Alphagan P Azopt Betagan Betoptic-S .25% Betoptic .5% Combigan Cosopt Latanoprost Lumigan Pilo Gel Propine Timoptic .25% Timoptic .5% Tobradex Trusopt Xalatan Zioptan Other	Sig:	1gtt OU qPM 1 drop both eyes right eye left eye once a day twice a day three (3) times a day four (4) times a day Other
None Alphagan P Azopt Betagan Betoptic-S .25% Betoptic .5% Combigan Cosopt Latanoprost Lumigan Pilo Gel Propine Timoptic .25% Timoptic .5% Tobradex Trusopt Xalatan Zioptan Other	Sig:	1gtt OU qPM 1 drop both eyes right eye left eye once a day twice a day three (3) times a day four (4) times a day Other

General Medical History

	You	Mom	Dad	Siblings
Hypertension:
Thyroid:
Cardiovascular:
Cancer:
Diabetes:
Cholesterol:

PATIENT MEDICAL HISTORY:	FAMILY MEDICAL HISTORY:

Primary Care Provider:

MED LIST:

Medication Allergies:

no know drug allergies Other

Surgeries or Injuries:
Pregnant or Nursing?:	No Yes Other
Vitamins/Supplements:	Fish Oil-Omega-3 Vit B12 Vit C Multi Ocuvite Other
Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other Discussed Cessation: Yes No Other
Notes:

Review of Systems

CONSTITUTIONAL:	No
SKIN:	No
NEUROLOGICAL:	No
ENDOCRINE:	No
EAR, NOSE THROAT:	No
RESPIRATORY:	No
CARDIOVASCULAR:	No
GASTROINTESTINAL:	No
GENITAL, KIDNEY, BLADDER:	No
MUSCLES, BONES, JOINTS:	No
BLOOD /LYMPH :	No
ALLERGIC / IMMUNOLOGIC :	No
PSYCHIATRIC:	No

Policies, Consent and Submit Data

HIPAA PRIVACY
ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

I have been presented with the Notice of Privacy Policy (the "Policy") of Hillsdale Eyecare (the "Provider"), and
have been offered a copy of such policy to keep for my records. Ask Receptionist for copy of Hippa policy if you desire.
I understand that even though I may refuse to sign this acknowledgment, Provider may still provide treatment.


Dilated Pupil Examination

Dilating the pupils with eye drops allows your Optometrist to obtain a better view inside your eyes in order to ensure optimal eye
health, and in some patients it is necessary to obtain an adequate view. Health problems such as glaucoma, cataracts, retinal degeneration,
diabetes, high blood pressure and other health problems can be detected, even before the onset of any symptoms or loss of vision. Prevention
is the best way to ensure you see well for many years to come. Young or older these problems can be avoided.

Dilation is strongly recommended if:

• 1. This is your first eye examination or your eyes were never dilated in a previous eye.
• 2. You have had a recent onset of unusual visual symptoms such as reduced vision, "floaters" or flashes of light.
• 3. You have a high amount of nearsightedness.
• 4. You or a family member has eye health problems, diabetes, high blood pressure or other health problems.
• 5. You have recently suffered head or eye injury.
• 6. The doctor is unable to get a good view of the internal eye without dilation

We now have a new way to view the health of your eyes without drops or the affects of the dilation drops. It is
call Imagenet 2000. It is a digital camera. No drops, No waiting, No blurred vision. Drive home or read without
any problems. Just a click and your image is taken and saved just like a digital camera. It's a wonderful way
to view and document your eye health. Now children of all ages and adults can have their eyes examined
without drops.

This procedure does have a fee of $39.00 that may be covered by some insurance but some do not. Ask the receptionist if it will be covered
by insurances. If the Optometrist recommends that your eyes be dilated with drops, there will be only a $20.00 fee.

Please select either YES or NO for each of the following questions. Thank you!

Yes, I do want a Dilated Fundus Exam with Imagenet	No, I do not want a Dilated Fundus Exam with Imagenet
Yes, I do want a Dilation with the drops	No, I do not want a Dilation

I understand that some diseases may go undiagnosed without a Dilated Fundus Exam.

Payment is due upon services rendered.

Present all insurance forms to the receptionist Before your examination.

I request that payment of authorized Medicare/or Medical Benefits be made either to me or on my behalf to
Dr. Beja for services furnished to me by the physician. 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 or the benefits payable for related services. I
understand fully that in the event my insurance company or financial responsible party does not pay for the services I receive, I will be
financially responsible for payment. I understand that if my account is sent to collections or to any attorney, additional charges or fees may
be billed at the discretion of the medical provider and added to the account on top of the billed charges for services rendered.


Please check, sign, and date that you have read and agree to the following and then hit the SUBMIT button to complete your online forms. Thank you!

Check:
Patient Signature:
Date: