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New Patient Intake Form

COVID-19 safety agreement

I agree:

How did you hear about our office?

Eye History

Do you wear glasses for: Required
Do you have blurred DISTANCE vision?
Do you have blurred NEAR vision?
Do you wear contact lenses?
If no, are you interested in contact lenses?
Do you have any issues with your current contact lenses?
Have you ever had eye surgery?
Have you ever had an eye injury?
Do your eyes feel tired or strained?
Do you experience frequent headaches?
Do your eyes burn/feel dry?
Do you see bright flashes of light?
Do you have itchy eyes?
Do you experience double (not blurred) vision?
Are you at the computer the majority of your day?
Do you have any specific visual demands such as golfing or tennis?

Medical History

Do you or anyone in your family have (please check all that apply):

High blood pressure: Required
Diabetes Required
High cholesterol Required
Heart disease Required
Thyroid disease Required
Cancer (or history of) Required
Glaucoma Required
Macular degeneration Required
Retinal problems Required
Do you smoke?
Do you consume alcohol?
Females, are you pregnant/breastfeeding?
Are you currently taking any prescribed OR over-the-counter medications (including eye drops)?
Are you allergic to any medications?

Our optometrists perform both routine eye exams for glasses and contacts, as well as medical eye exams. Should your exam include additional testing and treatment for a medical eye condition (ex: dry eye, diabetes, ocular allergies, or glaucoma), your medical insurance may be billed. Please let our staff or your optometrist know if you have any questions regarding this policy.

Financial Responsibility

We believe that you should not be surprised by your eye care costs. Visions by Victoria Rose will always do our best to verify your insurance eligibility prior to your appointment. There may be times thaat our doctors feel that a certain procedure is appropriate and necessary but is not covered by your insurance plan. We will provide you an estimated cost of these procedures when requested. When a patient agrees to any necessary procedure that is not covered by insurance, the patient is responsible for payment at the time of service.

Eye Health Screenings

Clarus digital image of the retina

Our doctors want every patient under the age of 4 to have the Clarus retinal image performed every year. This technology provides an ultra wide-field view of the retina and important structures of the eye, and eliminates the need for dilation drops in many (not all) cases. Comparing these images on an annual basis allows for early detection of eye disease. The fee for this image is $30 and is not usually covered by insurance.

Thanks for submitting!

Location

639 Veteran's Road West
Staten Island, NY 10309

Contact

718-966-9400
vr@visionsbyvr.com

Hours

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Closed

Closed

10AM–5:30PM

10AM–8PM

10AM–5:30PM

10AM–5:30PM

9:30AM - 4PM

Holiday Schedule

Dec 24 
Christmas Day
Dec 31 
New Years Day

Closed at 2pm
Closed 
Closed at 2pm
Closed 

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