See Clearly Today

Clear Vision Today, Healthy Eyes Tomorrow

Welcome! Please complete this form to help us provide you with the best possible care. We need your basic details to create and update your patient record.Your eye history helps us understand your vision needs and provide tailored care.

Optometrist

Dr. Cindy Joseph

1A Quaker Ridge Road, New Rochelle, NY, 10804

914.602.0114

First Name *

Last Name *

Date *

Parent/Guardian (for Minor Children):

Date of Birth *

Occupation *

Address *

City *

State *

Zip *

Telephone: Home *

Cell *

Work *

E-mail *

New Patient *
YesNo

Referred By

Last Eye Exam *

Reason For Today's Exam *

Describe Any Previous Injury, Disease Or Surgery Of The Eyes *

Contact Lens Wearer: Yes/No If NO, Are You Interested In Contact Lenses *
YesNo

Type of Insurance *

Do You Wear Glasses *
DistanceReaderBifocalProgressive

Last Medical Exam *

Primary Care Physician *

List All Medications You Are Currently Taking (Including Contraceptives) *

Seasonal Allergies *

Family History (select any that apply) *
DiabetesHypertensionGlaucomaMacular DegenerationRetinal Detachment

HIPAA PRIVACY POLICY *
I give Dr. Cindy Joseph consent to use or disclose my protected health information to carry out treatment as well as health care operations to assure quality reviews.
I have been informed that I may revoke this authorization before my first service if no that I have the right to review any changes to the privacy policy of this practice.
I understand I may revoke this consent at any time by making a request in writing.
I have provided a copy of my card here so, at the completion of my contact information and I consent to having my contact card be sent to me by email, if applicable.

Date *

How can we help you? Let’s talk.

Welcome to the Optometry Practice of Dr. Cindy Joseph, where advanced eye care meets personalized attention. Dr. Cindy provides thorough, patient-centered comprehensive eye exams for individuals of all ages

Office Hours

Tue 10AM-4:30PM
Wed 10AM-4:30PM
Thu 10AM-6PM
Fri 10AM-4PM

Contact Us

1A Quaker Ridge Road, New Rochelle, NY, 10804

914.602.0114

info@seewithdrcindy.com