Adult and Pediatric Eyecare

200 Midway Park Dr, Suite 1
Middletown, NY 10940

Online Patient Form

After completing all the forms, please submit your data on the final tab. Thank you!


Patient Information
First MI Last
Suffix Nickname Pronoun

Date of Birth Sex 

Address Line 1
Address Line 2
City State ZipCode

Home Phone
Work Phone
Other Phone
Cell Phone
Email Address
Preferred Contact Method

Marital Status Occupation Employer / School Name Hobbies
Parent or Guardian Drivers License #

Tap or click MEDICAL HISTORY tab above.

Medical History

Select all that apply to Your Medical History

List all systemic medications that you take, including injectables or OTC:

Do you have any allergies to medication?

Primary Care Provider 
When was your last medical exam? 
Are you currently pregnant? 
Do you smoke? 
Do you drink alcohol? 

Select all that apply to your Family Medical History List the family member with chosen condition:
Tap or click OCULAR HISTORY tab above.

Ocular History

Ocular History
When was your last eye exam?
Do you wear glasses?
If yes, what do you wear them for?
Do you wear contact lenses?
How many hours per day do you use electronic devices?
If you take eye medications including eye drops, please list:

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
Tap or click SUBMIT tab above.


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.

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

HIPAA Agreement
I acknowledge that I have read the Notice of Privacy (HIPAA) practices available at this webpage (
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 statement.

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.