New Patient Forms
Note: The original web page contains a multi-step interactive form with various input fields, checkboxes, radio buttons, signature areas, and a progress bar. These interactive elements are not supported by the CMS's available components and have been omitted. This representation focuses on the textual content and headings from the form for informational purposes.
Patient Information
Responsible Party
The preceding information is true to the best of my knowledge and I request any applicable payments of insurance be made on my behalf to Allied Vision Plainsboro for any services rendered. I authorize any holder of medical information about me to release to the insurance company and its agents any information needed to determine these benefits or benefits for related services. I understand that I am responsible for any referrals needed for services rendered here (if in a managed care insurance program), and for any fees not covered by my insurance company owed to Allied Vision Plainsboro.
Primary Insurance Information
Additional Insurance Information
Acknowledgement of Receipt
I acknowledge that I have received a copy of Allied Vision Plainsboro notice of Privacy Practices. Privacy Policy
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.
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.
Review of Systems:
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.
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.