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Patient Forms

If you are new to the office or a returning patient, please read through the privacy policy for the most updated HIPPA information and the Insurance Questions forms for up to date information.

Privacy Policy
Insurance Questions

New Patient Form

If you are new to the office, please fill out the New Patient Form
Click Here

EVERY Patient New or Returning MUST fill out the COVID Health Questionnaire before coming in to the office.

Fill out the form below, your responses will be submitted directly to the office email. We will call you if we need to Reschedule your appointment.

Covid Health Questionnaire

* Indicates required field

Name *

First

Last

If you have been exposed to a communicable disease, you may spread the disease to the optometrist, optometrist staff or other patients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you today or anyone else you have recently been in contact with have any of the following symptoms? *

Fever (defined as above 100.4F) Chills Cough Sore Throat Shortness of breath and/or trouble breathing Persistent muscle pain, pressure or tightness in the chest New loss of taste or smell None of the above

If Other please specify: *

Have you or others accompanying you to today's appointment traveled outside of our local area or outside of the US withing the past 14 days? *

Yes No

Have you, your child, others accompanying you today or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

Yes No

I understand that if the answer to any of these questions is yes, I may be asked to reschedule my appointment.

CONTACT

76 S Lexington Avenue
White Plains, NY 10606

Phone: 914-422-2686
Fax: 914-422-8248
toufexiseye@gmail.com

WE OFFER FREE PARKING

OFFICE HOURS

Monday 10am-6pm
Tuesday 10am-6pm
Wednesday 10am-3pm
Thursday 10am- 6pm
Friday 10am-3pm
Saturday Closed
Sunday Closed

Home
The Family
Insurance
Contact Lenses
Patient Forms
Resources
Products
- Lenses

Patient Forms

New Patient Form

EVERY Patient New or Returning MUST fill out the COVID Health Questionnaire before coming in to the office.Fill out the form below, your responses will be submitted directly to the office email. We will call you if we need to Reschedule your appointment.

Covid Health Questionnaire

If you have been exposed to a communicable disease, you may spread the disease to the optometrist, optometrist staff or other patients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

EVERY Patient New or Returning MUST fill out the COVID Health Questionnaire before coming in to the office.

Fill out the form below, your responses will be submitted directly to the office email. We will call you if we need to Reschedule your appointment.