Adult and Pediatric Eyecare
200 Midway Park Dr, Suite 1
Middletown, NY 10940
845-343-6919
Online Patient Form
After completing all the forms, please submit your data on the final tab. Thank you!
Demographics
Patient Information
First
MI
Last
Suffix
Nickname
Pronoun
he/him/his
she/her/hers
they/them/theirs
Date of Birth
Sex
Male
Female
Address Line 1
Address Line 2
City
State
NY
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
ZipCode
Home Phone
Work Phone
Other Phone
Cell Phone
Email Address
Preferred Contact Method
Text Message
Cell Phone
Email
Work Phone
Home Phone
Other Phone
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Occupation
Employer / School Name
Hobbies
Parent or Guardian
Drivers License # (only add this if DMV form is needed at this visit)
Social Security Number (this is needed for insurance verification purposes)
Is the Billing Address Different?
Billing Information
First
MI
Last
Suffix
Copy Address From Above
Address
City
State/Zip Code
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Is the patient under 18?
Parent's Name
School
Grade
Hobbies/Sports
Has your child received any special guidance/assistance/testing
(OT/PT, AIS, IEP, 504, RTI) etc...
Tap or click MEDICAL HISTORY tab above.
Medical History
Select all that apply to Your Medical History
Thyroid Disease
Diabetes
Rheumatoid Arthritis
Heart Disease
Asthma
Multiple Sclerosis
High Blood Pressure
Lyme Disease
High Cholesterol
Cancer
Allergies
Sinusitis
None
List all systemic medications that you take, including injectables or OTC:
Do you have any allergies to medication?
Yes
No
Primary Care Provider
When was your last medical exam?
Are you currently pregnant?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Select all that apply to your Family Medical History
List the family member with chosen condition:
Diabetes
High Cholesterol
High Blood Pressure
Thyroid Disease
None
I Don't Know My Family History
Tap or click OCULAR HISTORY tab above.
Ocular History
Ocular History
When was your last eye exam?
Do you wear glasses?
Yes
No
If yes, what do you wear them for?
Distance
Near
Both
Do you wear contact lenses?
Yes
No
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?
Flashes of light in your vision
Floating objects in your vision
Frequent headaches?
Dry Eyes
Select all that apply to your eye history
Amblyopia ("Lazy Eye")
Strabismus ("Eye Turn")
Glaucoma
High Eye Pressure or Glaucoma Suspect
Diabetic Retinopathy
Cataracts
Floaters
Iritis
Allergic Conjunctivitis
Vitreous Detachment
Choroidal Nevus or Freckle
Artificial Lens Implant after Cataract Surgery
Keratoconus
Retinal Tears, Holes, or Thinning
Retinal Detachment
Trauma to your Eyes or Head
None
Other (please explain):
Select all procedures that you have had to your eyes
Cataract Surgery
Refractive Surgery (LASIK or PRK)
Muscle Surgery for Strabismus
Glaucoma Surgery or Laser
Retinal Detachment Surgery or Laser
Foreign Body Removal
Injections for Macular Degeneration
Laser or Injections for Diabetic Retinopathy
Corneal Crosslinking
None
Other (please explain):
Select all that apply to your Family Ocular History
Retinal Detachment
Glaucoma
Cataracts
Macular Degeneration
Keratoconus
Other (please explain at right):
None
Tap or click SUBMIT tab above.
Submit
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.
Name
Date
HIPAA Agreement
I acknowledge that I have read the Notice of Privacy (HIPAA) practices available at this webpage (
https://www.adultandpediatriceyecare.com/privacy-practices
).
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.
Name
Date
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.