Welcome to Precision Eye Care of NJ

Today's Date:(Required)

Patient Name(Required)

First Last

Gender:(Required)

Male

Female

Other

Name you prefer to be called(Required)

Your Address:(Required)

APT:(Required)

State:(Required)

Zip code:(Required)

Home/Cell #:(Required)

Date of Birth:(Required)

Last 4 # Social(Required)

Email(Required)

Is it ok to Text /Email you?(Required)

Yes

Do you have insurance?(Required)

Yes, I have insurance

No, I will self-pay

INS Policy Holder Name:(Required)

First Last

Date of Birth (of policy holder)(Required)

4 # Social (of the policy holder)(Required)

Your Pharmacy Name/ Location:(Required)

How did you hear about our office?(Required)

Google

Facebook

Website

Other

Who may we thank for referring you to us?(Required)

Has anyone in your household been a patient here before?(Required)

Yes

Name(Required)

Occupation:(Required)

If Student grade(Required)

Hours spent on electronic devices (computer, ipad, iphone)(Required)

When was your last eye exam(Required)

Do you wear glasses(Required)

Yes

distance

reading

Both

Contact Lenses(Required)

Yes

Contact lens BRAND(Required)

Do you need a contact lens exam(Required)

Yes

Primary Care Physician(Required)

Last physical(Required)

Allergies to medication?(Required)

Yes

Please list which medications you are allergic to?(Required)

Are you able to make financial decisions for yourself?(Required)

Yes

Who is responsible for making those decisions?(Required)

Phone Number(Required)

Check health issues :(Required)

Major Surgeries(Required)

Please hand us your medication list or otherwise please list them here :(Required)

HIPPA COMPLIANCE ACKNOWLDGEMENT OF RECEIPT

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of privacy practices. We protect your health information and what rights you have regarding it. If we need to disclose your health information outside of our office we will ask for your written permission. If you would like a copy of this policy please feel free to ask for one.

Signature(Required)

PRECISION EYE CARE CANCELLATION POLICY

Precision Eye Care's goal is to provide patients with quality eye care in a timely manner. We have implemented a NO SHOW and CANCELLATION POLICY which enables us to better utilize available appointments for our patients in need of care. The following policy is with regard to patients who fail to keep their scheduled office appointments.

Patients who fail to show up to their scheduled appointment or did not notify the office within 24 hours of their scheduled appointment time, shall be subjected to a "NO SHOW/CANCELLATION FEE" of $50.00. Consideration will be given, at doctor's discretion, in the event of an actual emergency where prior notice could not be given.

Please be courteous and call Precision Eye Care of NJ promptly if you're unable to attend your appointment. This time will be relocated to someone who is in urgent need of treatment. Available appointments are in high demand and your early cancellation will give another patient the possibility to have access to a visit.

The fee associated with the cancellation policy is not covered by the insurance and is therefore the sole responsibility of the patient.

TO CANCEL or RESCHEDULE please call or text (732) 842-9177. If you have any problem getting through, you can always leave a message with your name, appointment date and cancellation reason or request for rescheduling.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. A photocopy of this consent shall be considered as valid as original.

PATIENT/ PATIENT REPRESENTATIVE SIGNATURE:

PRINT PATIENT NAME:(Required)

First Last

Date(Required)

SIGNATURE:(Required)

If you're not the Patient, please identify your relationship to the patient.(Required)

Parent

Legal Guardian

Power of Attorney

Annual Contact Lens Agreement Precision Eye Care of NJ

Contact lenses are medical devices that require additional testing to ensure safety and an accurate prescription. An annual contact lens evaluation is required every year for all contact lens wearers in order to prescribe contacts. The fee for this evaluation is separate froM the fee for the routine eye exam and is not refundable. Some vision plans do cover all or part of this fee, while others do no. Any amount not covered by your vision plan is due In full at the time of service.

Contact Lens Evaltiation Fee:
- New patient soft lens evaluation: Sphere: $150 Astigmatism/ Toric: $170 lyiultfocal Starts $195
- Established patient soft lens evalUation: Sao and up
- New Patient RCP/Hybrid evaluation: $250 and up (based on complexity)
- Established patient RGP/ilybrid evalusition: $170 and up

The exact fee within these ranges depends on the exact type of lens and complexity, and will be determined by your doctor. If you have questiont about the expected fee for your evaluation, you can discuss that with your doctor.

The contact lens evaluation fee includes:
1. All of the necessary measurements required to determine the right fit and prescription for you.
2. Any training necessary for the insertion and removal of your lenses up to 2 training, any additional training $45.
3. Any follow ups needed to finalize the prescription of your contact lenses, or to address issues you may be having with your lenses (up to 2 follow ups)
4. Trial pair (if neededfindicated).

The contact lens evaluation does not include your'annual supply of contact lenses, which can be ordered after the prescription has been finalized. It also does not include medical office visits for issues unrelated to the evaluation of your contact lenses, like dry eye, eye infection, injuries and ocular disease.

By signing this form, you are acknoMedging that:
- Contact lens evaluation fees are non-refundable and payment is due at time of service.
-Your prescription is valid for one year.
- Proper care of your lenses is expected. Failure to properly care for your lenses may result in numerous eye problems, such as corneal ulcers and potential loss of vision.

Patient Name(Required)

First Last

Guardian name:(Required)

First Last

Patient/ Guardian Signature:(Required)

Date(Required)