Skip to main content

Book an Appointment

Call Our Locations

Hours & Location
- West Orange
- Old Bridge
Our Eye Doctor
- The Staff
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

Hours & Location
- West Orange
- Old Bridge
Our Eye Doctor
- The Staff
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

Return to top of menu

Hours & Location
- West Orange
- Old Bridge
Our Eye Doctor
- The Staff
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

Hours & Location
- West Orange
- Old Bridge
Our Eye Doctor
- The Staff
Advanced Services
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

Return to top of menu

Home » Contact Us » Patient Registration Form

Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address
Please provide us your email address.
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity*
Marital Status
Marital Status - Other
Please provide your marital status.
Employment Status
Employment Status - Other
Please provide your employment status.
Employer
Occupation
How were you referred to our office?
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
Eye History
Please check off any current conditions you suffer from
- I stopped wearing glasses
- I stopped wearing contact lenses
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature*
Date*
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Δ

Search:

Request An Appointment

Patient History Form

Patient History Form

West Orange Family Eyecare

414 Eagle Rock Ave, Suite 206A
West Orange, NJ 07052

Phone/Text: 973-325-0500
Fax: 973-325-0075
Email: westorangefamilyeyecare@gmail.com
(Do not send personal health information by email.)

Monday: 10:00 AM - 6:00 PM
Tuesday: 10:00 AM - 6:00 PM
Wednesday: Closed
Thursday: 10:00 AM - 6:00 PM
Friday: 10:00 AM - 6:00 PM
Saturday: We are open two Saturdays a month.
Please call us to inquire about specific dates and availability.
Sunday: Closed

Old Bridge Eyecare

3384 U.S. 9
Old Bridge, NJ 08857

Phone/Text: 973-325-0500

Monday: Closed
Tuesday: Closed
Wednesday: 10:00 AM - 6:00 PM
Thursday: Closed
Friday: Closed
Saturday: We are open two Saturdays a month.
Please call us to inquire about specific dates and availability.
Sunday: Closed

Home
Contact Us
What’s New
Disclaimer

Home
Contact Us
What’s New
Disclaimer

Schedule Appointment

Speak Field

Old Bridge Eyecare
3384 U.S. 9
Old Bridge, NJ 08857
https://www.westorangefamilyeyecare.com

West Orange Family Eyecare
414 Eagle Rock Ave, Suite 206A
West Orange, NJ 07052
https://www.westorangefamilyeyecare.com

© 2025 Powered by

Accessibility
Sitemap
Privacy
Disclaimer
Login

Call Us

Call West Orange 973-325-0500

Call Old Bridge 973-325-0500

Text Us

Text Us West Orange 973-325-0500 Text Us Old Bridge 732-402-8800

Search: