Williston Park Eye Associates
Eye Wellness - Ophthalmology of Long Island
1603 Jericho Turnpike New Hyde Park, NY 11040
Call us: 516-747-4011
We are updating our records and inputting your current information into the electronic health records system
Please fill in the requested information below:
LAST NAME: _______________________ FIRST NAME: _____________________
ADDRESS: _________________________________________________________
_________________________________________________________
PHONE NUMBER: ( ) __________________________
DATE OF BIRTH: _________/_________/____________
SS#: ________________________________
NAME OF INSURANCE PRIMARY: ________________________SECONDARY____________
NAME OF PRIMARY INSURED: ________________________DATE OF BIRTH________/________/_________
PRIMARY CARE DOCTOR: _________________________________
PRIMARY CARE DOCTOR FAX NUMBER: ( )_______________________
PHARMACY NAME :______________________________
PHARMACY ADDRESS: ______________________________________
______________________________________
______________________________________
PHARMACY PHONE NUMBER: ( )_____________________________
MEDICINES YOU NAME DOSAGE
CURRENTLY TAKE: ___________________ __________
___________________ __________
___________________ __________
___________________ __________
___________________ __________
ALLERGIES TO MEDICINES:
DO YOU SMOKE CIGARETTE’S? _______ YES ________ NO
If yes how much per day?_____________
E-MAIL: _______________________________
(for secure communication of reports, if needed)
Click the Icon to download and print the Patient Questionaire
