Dear Patient:
Thank you for scheduling an appointment at our office:
1115 Fifth Avenue, New York, NY 10128

Please print and fill out the forms below.
On the day of your appointment please bring them along with:

  • Your Current Insurance Card
  • A referral from your primary care physician (if required by your insurance company)
  • Current glasses (if worn). Did you know that Fifth Avenue EyeCare and Surgery has a full service optical shop?
  • Current contact lenses or prescription (if worn)
  • Medication List or bring actual medications

We look forward to seeing you and again thank you for allowing us to participate in your eye care.


Patient HIPPA Consent Form

Medical Questionnaire

Medical Release Form