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Services
Patient Center
Optical
- Brands We Carry
Contact
Appointments
- Online Forms
  - Privacy and Policy

(860) 376-2848

Home
About
Services
Patient Center
Optical
- Brands We Carry
Contact
Appointments
- Online Forms
  - Privacy and Policy

(860) 376-2848 Book Appointment

Home

New Patient Form

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!

Title

Mr. Mrs. Miss Ms. Other

Preferred Pronouns

First Name*

Comments

Middle Initial

Last Name*

Preferred Name

Street Address*

City*

State*

Zip Code*

Social Security Number

Date of Birth

Primary Phone Number *

Texting?

Yes No

Email Address *

Other Phone Number

Emergency Contact:

Name

Relationship

Phone

PRIMARY INSURANCE:

Relation to Primary Insured: *

Name of Insurance Company*

Insurance ID Number*

Policy Holder's Name*

Date of Birth:*

Policy Holder’s SSN

SECONDARY INSURANCE (If Applicable):

Relation to Primary Insured:

Name of Insurance Company

Insurance ID Number

Policy Holder's Name

Date of Birth:

Policy Holder’s SSN

I consent to my glasses or contact lens prescriptions being emailed to me if I request it even though email is not HIPAA compliant

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.

Signature of Patient/Legal Guardian*

Date *

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.

Signature of Patient/Legal Guardian*

Race

Preferred Language

English Spanish Chinese French Hindi

Primary Care Physician

Clinic Name

Office Address

Phone Number

Preferred Pharmacy*

HEALTH HISTORY

Main Reason for Today's Exam

Last Eye Exam

Last Physical Exam

Height

Weight

Are you pregnant or nursing?

Yes No

Past or Current Illnesses or Injuries

Past Surgeries (that relate to eyes or major medical event)

Current Medications *

Current Eye Drops

Allergies/Sensitivities to Medications*

Specific Allergies*

HAVE YOU HAD THE COVID-19 VACCINE?

Yes No

Date of Vaccine

EYE HISTORY

Blurry vision distance without glasses?

Yes No

Blurry vision near without glasses?

Yes No

Floaters?

Yes No

Eye Pain?

Yes No

Dry, gritty or burning sensation of the eye?

Yes No

Amblyopia (lazy eye)?

Yes No

Macular Degeneration?

Yes No

History of eye surgery?

Yes No

Have you ever had a retinal detachment?

Yes No

A history of ocular trauma?

Yes No

Glaucoma?

Yes No

GLASSES HISTORY

Have you ever worn glasses?

Yes No

Do you currently wear glasses?

Yes No

If yes, type of glasses worn?

Distance Reading Bifocals Progressives (No Line Bifocal)

Have you ever worn contact lenses?

Yes No

Do you currently wear contact lenses?

Yes No

If yes, brand/type of contact lenses?

SOCIAL HISTORY

Current Occupation

Years

Employer

Do you smoke cigarettes?

Yes No

Do you drink alcohol?

Yes No

MEDICAL HISTORY

Do you have high blood pressure?

Yes No

Diabetes?

Yes No

High cholesterol?

Yes No

HIV or AIDS?

Yes No

Arthritis?

Yes No

Asthma ?

Yes No

COPD or lung problems?

Yes No

Thyroid condition?

Yes No

A history of stroke?

Yes No

FAMILY HISTORY

Macular Degeneration

Yes No

Glaucoma

Yes No

Color Blindness

Yes No

Blindness

Yes No

Diabetes

Yes No

Cancer

Yes No

High Blood Pressure

Yes No

Thyroid

Yes No

Other

Please do not submit any Protected Health Information (PHI).

Error!

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

--mi

Griswold Eye Care

Address

8 N Main St
Jewett City, CT 06351

Contact Information (860) 376-2848

(860) 376-4821

[email protected]

8 N Main St
Jewett City, CT 06351

(860) 376-2848

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