New Patients

Welcome New Patients

Inquiries regarding the website should be directed to portal@shields.md

Important Information For Your Visit

• Your visit will be 6-8 hours long.
• Your eyes will be dilated (driving a vehicle is at your own risk)
• You will have a series of diagnostic testing.
• There will be a period of waiting between testing.
• You may eat breakfast and take medications.
• You may, and we encourage you to, bring a lunch.
No surgical procedures will be performed on your initial visit.

Before You Leave Home You Will Need

• A hotel or place to stay.
• Finances for your visit and finances for surgery.
• Finances to use while you are here.
• Transportation arrangements.
• Send all testing to us prior to your visit.
• Current, valid insurance card(s)
• Valid insurance referral/valid out of network authorization for your exam visit and testing.
• Glasses if they have been prescribed for you.
• Someone who can interpret English to your native language for you.

Let’s Prepare For Your Appointment

Reason For Visit

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What is the reason for your upcoming appointment with us?

 

Please FILL OUT, PRINT, and BRING the following form with you to your appointment.

 

DOWNLOAD FORM

Medical History

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Your medical history will need to be updated through our patient portal prior to your visit.

Activate Your Patient Portal: If you have successfully accessed your patient portal previously, you may skip this step.

Trouble accessing your Patient Portal? Contact portal@shields.md

Name:*
Date of Birth:*
 / 
 / 
Appointment Date:*
E-mail:*
Word Verification:
Click submit to activate "My Wills Eye Patient Portal"

You can only activate your portal AFTER you have an appointment date.

After submission you shouldimmediatelyreceive a confirmation email.

Within the next 24 hours, instructions on how to access your account will be sent from Modernizing Medicine.

 

Patient Information & History:
Once you click the patient portal below and log in a new screen will show tabs on the left side. You may review Contact Information and Insurance but please DO NOT make changes. You will need to  review the remaining tabs and make necessary changes, then click save & continue each time.

1.) Pharmacy: Click “Add Surescripts Pharmacy” and add your home pharmacy. If your pharmacy is not listed click “Add Manual Pharmacy.”
2.) Past History & Ocular History: Fill out information under both tabs by checking personally relevant boxes in each section.
3.) Medication: List all medications you are currently taking by typing them into the search bar and selecting them. Fill in all referring blanks such as frequency, date started, etc.
4.) Allergies: If applicable click “Add Allergies.” Search for and select any allergies that you have. You will need to describe the reaction, date when the allergy was recorded, and state if the allergy is still active.

Access Patient Portal:

modmed

Trouble accessing your Patient Portal? Contact portal@shields.md

Forms

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Please fill out and submit the following form:

Patient Information

Patient Name:*
Date of Birth:*
 / 
 / 
Patient's E-mail:

Referring Doctor Information

Referring Doctor's Name:*
Referring Doctor's Address:*
Referring Doctor's Phone:*
-
Referring Doctor's Fax:
-
Referring Doctor's E-mail:

Ophthalmologist's Information

Please type "SAME" if doctor is also your referring physician.

Ophthalmologist's Name:*
Ophthalmologist's Address:
Ophthalmologist's Phone:
-
Ophthalmologist's Fax:
-
Ophthalmologist's Email:

Medical Oncologist's Information

(NOT Ocular Oncologist)

Oncologist's Name:
Oncologist's Address:
Oncologist's Phone:
-
Oncologist's Fax:
-
Oncologist's Email:

Family Medical Doctor Information

Family Medical Doctor's Name:*
Family Medical Doctor's Address*
Family Medical Doctor's Phone:*
-
Family Medical Doctor's Fax
-
Family Medical Doctor's Email:

Other Doctor Information

Other Doctor's Name:
Other Doctor's Specialty:
Other Doctor's Address:
Other Doctor's Phone:
-
Other Doctor's Fax
-
Other Doctor's Email:

Other Doctor Information

Other Doctor's Name:(1)
Other Doctor's Specialty:(1)
Other Doctor's Address:(1)
Other Doctor's Phone:(1)
-
Other Doctor's Fax(1)
-
Other Doctor's Email:(1)

Pharmacy Information

Pharmacy Name:*
Pharmacy Address:*
Pharmacy Phone:*
-
Pharmacy Fax:*
-
Word Verification:

Problems with the form? Please DOWNLOAD FORM and email to registration@shields.md 

 

 

Eye Photographs and OCTs

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The Ocular Oncology Services requires ALL previous testing and high-quality photographs with the proper dates uploaded before we can schedule your appointment. Please upload your files below:

 

Last Name:*
DOB:*
 / 
 / 
Appointment Date:
 / 
 / 
Upload Image (max 10):*
Image Date:*
Type:*
Captcha:

 

*If you are unable to use this form please email all files to photography@shields.md with Last Name and Date of Birth as the email subject.

 

 

If you are unable to upload or email your photographs, you will be required to mail all hardcopies ASAP to:

 

Ocular Oncology Service

840 Walnut Street, Suite 1440

Philadelphia, PA 19107

 

Hardcopies must arrive before your appointment.

Physical Exam

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Get a physical and have your physician fill out the Physical Evaluation form. Please bring with you on your first visit. Your physical exam needs to be less than 30 days old. This form is for all patients and is required for all patients undergoing surgery. No other form will be accepted by our surgery center. Should patients not have the physical form complete, it would delay any surgical procedure that may be required. For a child, their pediatrician must complete the form prior to your initial visit.

 

DOWNLOAD FORM

Testing

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Because many of our patients travel great distances and will need to have surgery within days of our initial evaluation, we require the following tests be performed by your primary care doctor prior to your initial visit and to bring the results (if available) with you to your appointment. Should the patient not have the necessary testing, it would delay any surgical procedure that may be required.

 

You will need to have all the necessary testing completed prior to your visit:
• CBC with Differential (required for patients 21 years or older ) less than 30 days old (no fasting required.)

• Liver enzyme (LDH, SGOT, ALKP, GGT, SGPT) less than 30 days old

• EKG (required for patients 50 years or older) less than 6 months old

• EKG less than 30 days old and prior EKG to compare (if patient has a history of heart disease.) Cardiologist clearance for surgery may be required for certain conditions.

• New children with Retinoblastoma are required to get a hearing test and physical.

• CBC if on Chemo less than 30 days old.

 

If you need to download this section, please click here.

Insurance Authorization

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If insurance is not accepted, you will need an out of network authorization from your referring physician.

It is the patient’s responsibility to contact your insurance carrier regarding your benefits and to be sure that Shields & Shields (not Wills Eye) is in your network. If you find that we are not in your network, please give the following authorization letter to your referring doctor’s office to obtain an out of network authorization.

 

DOWNLOAD AUTHORIZATION LETTER

 

DOWNLOAD PATIENT VISIT INSURANCE CPT CODES

 

All out of state Medicaid insurances must have an out of network authorization AND a single case agreement.

 

We need all out of network authorizations to be done immediately, they take a few days to obtain! All authorizations must be given to our office by 3:00PM on the Thursday before your appointment. Please call our office immediately with your authorization number and information when obtained. You may contact Marie at 215-928-3105. If you come to Shields & Shields without your authorization or referral you will be considered self pay. We do not accept personal checks.

 

Insurance CPT Codes

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Not sure of what CPT codes we use?

 

DOWNLOAD PATIENT VISIT INSURANCE CPT CODES

New Retinoblastoma Patients

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Are you a a new patient with RETINOBLASTOMA treated elsewhere?


Please download the following form and follow ALL instructions provided.

 

DOWNLOAD NEW RETINOBLASTOMA PATIENT FORMS

You’re Complete!

Once you have completed every item on the list then you’re ready for your first appointment! We look forward to seeing you at your scheduled time.

Getting Here

The Ocular Oncology Service at Wills Eye Hospital is only about a 30 minute drive from the airport. Amtrak runs often and Wills Eye Hospital is easily accessible by public transportation. Philadelphia has an excellent transit system with trains, buses, and subways.