Existing Patient Forms – Plainsboro

Name: Allied Vision Plainsboro
Address: 10 Schalks Crossing Road, Plainsboro Center, New Jersey, 08536, United States
Telephone: (609) 275-8989

Step 1 of 2 - Medical Information

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Medical History
Vision 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.
Name
First Last
Date
MM slash DD slash YYYY
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”)

	You	Family	You and Family
Allergies
Arthritis
Asthma
Autoimmune Disorder
Cancer
Diabetes
Gastrointestinal Disease
Psychiatric Disorders
Thyroid Disease
Glaucoma
Lazy Eye
Headache
Heart Disease
High Blood Pressure
High Cholesterol
Lung Problems
Neurological Problems
Genito/Urinary
Skin Conditions
Eye/Head Injury
Eye Surgery
Other Eye Disease

Gender?
- Male
- Female
Are 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 Consent
During 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.

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
Signature
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Existing Patient Forms – Plainsboro

Step 1 of 2 - Medical Information

Medical History

Review of Systems:

Optos Consent