New Patient Form

Please fill out the form below and click submit to fill out our New Patient form. 

Welcome to Griswold Eye Care. We appreciate your time in answering the questions on this form. Your overall health relates to your eye health so each section is important. Thank you!

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Texting?
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Emergency Contact:

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PRIMARY INSURANCE:

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SECONDARY INSURANCE (If Applicable):

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HIPAA POLICY: Please read carefully.

I agree to allow my medical information be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am aware that Griswold Eye Care has a Notice of privacy practices available to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records.

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OFFICE POLICY: Please read carefully.

In order to control the cost of billing we require that the patient’s portion of costs is due at the time of services rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance.

All glasses sales are final and cannot be canceled or returned as they are all custom made. There will be a service charge on all returned checks. We require at least 24 hours notice for any cancellations or rescheduled appointments. Any late cancellations or missed appointments are subject to a $50 fee. I acknowledge and accept the above policies.

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Preferred Language
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HEALTH HISTORY

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Are you pregnant or nursing?
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HAVE YOU HAD THE COVID-19 VACCINE?
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EYE HISTORY

Blurry vision distance without glasses?
Blurry vision near without glasses?
Floaters?
Eye Pain?
Dry, gritty or burning sensation of the eye?
Amblyopia (lazy eye)?
Macular Degeneration?
History of eye surgery?
Have you ever had a retinal detachment?
A history of ocular trauma?
Glaucoma?

GLASSES HISTORY

Have you ever worn glasses?
Do you currently wear glasses?
If yes, type of glasses worn?
Have you ever worn contact lenses?
Do you currently wear contact lenses?
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SOCIAL HISTORY

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Do you smoke cigarettes?
Do you drink alcohol?

MEDICAL HISTORY

Do you have high blood pressure?
Diabetes?
High cholesterol?
HIV or AIDS?
Arthritis?
Asthma ?
COPD or lung problems?
Thyroid condition?
A history of stroke?

FAMILY HISTORY

Macular Degeneration
Glaucoma
Color Blindness
Blindness
Diabetes
Cancer
High Blood Pressure
Thyroid
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Please do not submit any Protected Health Information (PHI).

Location and Hours

8 N Main St, Jewett City, CT 06351

Monday  

8:30 am - 12:00 pm

1:00 pm - 4:30 pm

Tuesday  

8:30 am - 12:00 pm

1:00 pm - 6:00 pm

Wednesday  

8:30 am - 12:00 pm

1:00 pm - 6:00 pm

Thursday  

8:30 am - 12:00 pm

1:00 pm - 4:30 pm

Friday  

8:30 am - 12:00 pm

PM Closed

Saturday  

Closed

Sunday  

Closed

Location