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Patient Medical History Forms

To help make your visit more thorough and productive, please click below.

New Patients:

Click here for our welcome form!

    Established Patients:

    Click here to update your patient history regarding medication, medical & vision insurances, and medical history.


    Prefer paper? Download the paperwork here.

    You may download, print, and fill out the examination forms before you come into the office or you can fill out the online patient registration and the authorization release forms online.

    You can:

    • Email it to
    • Fax it to 1-732-679-6980 or
    • Print it out and bring it with you.

    About Us

    Welcome to Family Eye Care in Old Bridge, NJ!

    Dr. Roth and his team of eye care professionals are here to care for all of your vision needs. We handle everything from adult and children's eye exams and hard-to-fit contact lenses, to eye emergencies, treatment of eye diseases and co-management of LASIK and other laser vision surgeries.

    Great Vision, Advice, Technology and Fit

    By staying current with the latest developments in eye care, prescription lenses and advances in contact lens technology our vision center can provide you with the best vision, advice and fit today—and in the years to come. Our optometrist and staff takes pride in building lasting relationships with our patients, which is why we take the time to get to know you, your vision requirements and your lifestyle needs.

    Family Eye Care is a unique practice. We specialize in medical eye care and specialty contact lenses, but we also practice general optometry. Read about our featured services below.

    Dr. Moshe Roth, O.D.
    african american getting eye exam in old bridge nj
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    Family Eye Care Staff in Old Bridge, NJ
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    3111 U.S. 9
    Old Bridge, NJ 08857
    Forms of Payment

    We Accept:

    • discover
    • mastercard
    • visa
    • 9:00 AM - 5:30 PM
    • 9:00 AM - 5:30 PM
    • 9:00 AM - 5:30 PM
    • 9:00 AM - 5:30 PM
    • 9:00 AM - 2:30 PM
    • Closed
    • Closed

    Appointment times may vary so call us for availability.

    Schedule An Appointment
    Medical History Forms
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    Our Eye Care Practice in Old Bridge

    optometrist, Eye Doctor Showing Eyeglasses in Old Bridge, NJ

    With an office in Old Bridge, eye doctors at Family Eye Care have been providing New Jersey with quality eye care for many years. Our practice specializes in the Treatment of School Learning Problems, Lazy Eye, Vision Therapy, Ortho-K: Non-Surgical Vision Correction, ADD/ADHD, Autism, Dyslexia, Brain Injury, Concussions, Neuro-Optometric Rehabilitation, Specialty & Standard Contact Lenses, Keratoconus, Color Blindness

    Call us to make an appointment with our optometrist to talk about your eyeglasses, contact lenses or specialty lens needs. Drop in anytime to browse through our large selection of designer eyeglass frames and sunglasses!

    Our Family Eye Care Team Ready To Help You in Old Bridge

    optometrist, Eye Doctor Showing Eyeglasses in Old Bridge, NJ

    Our eye care center in Old Bridge offers a full range of eye health services to clients of all ages from children to older adults.

    optometrist, Eye Doctor Showing Eyeglasses in Old Bridge, NJ

    We will check over your child's vision to see if they are in need of any vision therapy & a complete functional vision exam.

    optometrist, Eye Doctor Showing Eyeglasses in Old Bridge, NJ

    We treat many patients for eye diseases such as glaucoma, cataracts, conjunctivitis, dry eye, etc.

    Have An Eye Care Emergency?

    Please call our office at: 732-679-2020, if you experience loss of vision, double vision, swelling, infection or any eye emergency, contact us immediately for guidance. We’ll help you with the best treatment to prevent complications and promote long-lasting clear eyesight.

    Use your best judgment on urgency, if you feel you need to find the nearest emergency room or you would like to review our emergency page of tips, it’s up to you.

    Wondering about payment plans?
    Check Out Our Insurance Plans.

    eye doctor, Woman's eye, ad for Eye Care Emergencies in Old Bridge, NJ

    Website Accessibility Policy

    Our commitment and approach to maintaining an accessible website

    Our practice is committed to providing a website that is accessible to the widest possible audience, regardless of technology or ability. We have made every effort to make our website accessible and easy to use by following the available standards and guidelines.

    Website standards

    Our website seeks to conform with Worldwide Web Consortium (W3C) Web Content Accessibility Guidelines. In that regard, this website seeks to comply with Level AA and Level AAA compliance, as practicable.

    Accessibility features of this website

    • Screen readers – To assist our visitors who are visually impaired or blind, our website is compatible with screen reading software.
    • Code Compliance – This site was built using code compliant with W3C standards for HTML and CSS. Standards compliant code means that the site displays correctly in current browsers and ensures that it will display correctly in future browsers.
    • Text Alternative – With the exception of decorative imagery, all non-text content presented to the user has a text alternative that serves the equivalent purpose. Screen readers can then present this alternate information to the user in place of the image.
    • ARIA Landmarks – We use ARIA landmarks to identify regions of the page allowing those with screen readers to jump to different sections of the page.
    • Skip to Main Content – Our pages all contain a skip to main content link allowing users to jump directly to the page’s main content, avoiding the header content from being read aloud repeatedly.
    • Accessible Forms – Our forms have the proper markup to associate labels with their form controls making it easier for screen readers to present the form information to the user.
    • Headings and Lists – We use the proper markup for headings and lists, i.e. h1-h6 and ol, ul and dl for lists. Heading markup will allow assistive technologies to present the heading status of text to a user. A screen reader can recognize the code and announce the text as a heading with its level, beep or provide some other auditory indicator. Some assistive technologies allow users to navigate from list to list or item to item.
    • CSS – We use CSS to control visual presentation of text. This will allow users to modify, via the user agent, the visual characteristics of the text to meet their requirement. The text characteristics include aspects such as size, color, font family and relative placement.
    • Resizing Text – Text can be resized without assistive technology up to 200 percent without loss of content or functionality.
    • Raster Images – We avoid the use of text in raster images, this allows user agents to read aloud any text on the page and apply custom style sheets to make the text more legible.
    • Keyboard Interface – The site is designed with consideration for people unable to use a mouse. The website can be navigated using your computer’s keyboard or by using other assistive devices. All functionality of the content is operable through a keyboard interface without requiring specific timings for individual keystroked. When all functionality of content can be operated through a keyboard or keyboard interface, it can be operated by those with no vision as well as by those who must use alternate keyboards or input devices that act as keyboard emulators like speech input software or on-screen keyboards.
    • Flashing Content – Web pages do not contain anything that flashes more than three times in any one second period, or the flash is below the general flash and red flash thresholds. These effects are known to cause seizures if the flashes are bright and large enough.
    • Page Titles – Our web pages have titles that describe topic or purpose. Descriptive titles help users find content, orient themselves within it, and navigate through it. A descriptive title allows a user to easily identify what Web page they are using and to tell when the Web page has changed. The title can be used to identify the Web page without requiring users to read or interpret page content. Users can more quickly identify the content they need when accurate, descriptive titles appear in site maps or lists of search results. When descriptive titles are used within link text, they help users navigate more precisely to the content they are interested in.
    • Locating Content – More than one way is available to locate a Web page within a set of Web pages. We provide breadcrumbs, and site maps. This makes it possible for users to locate content in a manner that best meets their needs. Users may find one technique easier or more comprehensible to use than another.
    • Highlighting – The majority of our web site components allow for highlighting by the user agent when they receive focus.
    • Default Language – The default human language of each Web page can be programmatically determined. Speech synthesizers that support multiple languages will be able to orient and adapt to the pronunciation and syntax that are specific to the language of the page, speaking the text in the appropriate accent with proper pronunciation.
    • Component Focus – When any of our components receive focus, they do not initiate a change of context, i.e. forms submitted automatically when a component receives focus, new windows launched when a component receives focus.
    • Consistent Navigation – We have a consistent navigation across our web pages. This technique makes the placement of navigational components more predictable.
    • Form Input Errors – In forms, if an input error is automatically detected, the item that is in error is identified and the error is described to the user in text.
    • Proper Coding – Elements have complete start and end tags, elements are nested according to their specifications, elements do not contain duplicate attributes, and any IDs are unique. These errors that are known to cause problems for assistive technologies when they are trying to parse content which involve having opening and closing tags that are not used according to specification.
    • Portable Document Format (PDFs) – Some documents on this website are in PDF format. You need Adobe Acrobat to open these files. You can download Acrobat for free. Download Adobe Acrobat.


    While we strive to adhere to the accepted guidelines and the highest standards for accessibility and usability, it is not always possible to do so in all areas of the website.

    Future Efforts

    We are currently working to achieve Level AA and Level AAA conformance to the Web Content Accessibility Guidelines (WCAG) 2.0, as practicable.

    How to send feedback on this website’s accessibility

    We welcome feedback on the accessibility of this website or if, for any reason, you are unable to access any part of this website, please contact us immediately.

    Email us at:

    Phone us at:
    (732) 679-2020

    Write to us at:
    3111 U.S. 9
    Old Bridge NJ

    Optometrist near East Brunswick NJ

    Office Hours

    • 9:00 AM - 5:30 PM

    • 9:00 AM - 5:30 PM

    • 9:00 AM - 5:30 PM

    • 9:00 AM - 5:30 PM

    • 9:00 AM - 2:30 PM

    • Closed

    • Closed

    Appointment times may vary so call us for availability.

    Book My Eye Exam

    Call Now! 732-679-2020

    Our Eye Care Services

    contacts eye close up woman

    Specialty Contacts

    Visit our optometrist in East Brunswck for a Keratoconus or Ortho-K contact lenses fitting.

    Read about Ortho-K

    Blue Eyed Shy Girl 1280x480

    Pediatric Eye Care

    Dr. Roth offers eye exams for kids as early as 3 months old. Book a consultation today!

    Read about pediatric vision

    blue eyes

    Dry Eye Treatment

    Dry eye is an incurable eye condition but Dr. Roth can help you manage your symptoms.

    Read about dry eyes

    Our Eye Doctor is Proud to Serve East Brunswick

    The East Brunswick township has a lot to offer to it's residents and tourists, including:

    • Playhouse 22 - Community Theatre and Performing Arts Center where the residents of East Brunswick, enjoyed many hit musicals, dramas, comedies and original plays.
    • If you like canoeing or kayaking visit Farrington Lake and Westons Mill Pond located just a short drive from the city center.
    • Do you like golf? Take advantage of the town's public golf course (Tamarack).
    • If you happen to visit the township in August visit The Middlesex County Fair - seven days of family fun and great food.

    Read Our Reviews

    Everything was great all the staff, every part of the process was perfect. Dr. Roth is an amazing doctor.
    5 days ago
    - Michael J.
    Dr. Moshe and his staff were excellent! I have very complex eye issues and he did an extremely thorough exam and developed a plan to get me on my way to better vision! I would highly recommend Family Eye Care to all!
    6 days ago
    - Karen E.
    I had a wonderful experience by Dr.Roth and his team. Their extensive knowledge and attentive care helped me so much
    6 days ago
    - chava t.
    From the moment I made the appointment to the time I walked out the door it was such a pleasant experience. They are kind courteous gracious and very professional. Ryanne at the front desk was helpful and made it easy to set up an appointment. Katherine the technician, knew her stuff and was so sweet throughout her time with me. Dr Steffani Tiomno was amazing. She was thorough and took her time with my exam. She explained everything and asked me over and over if I had any questions. If I could this place would get 10 stars. Very blessed to have found this place.
    3 weeks ago
    - Gladys Z.
    Family Eye Care, Old Bridge... The staff was very efficient, courteous and informative, from the desk help to the techs. Phone calls were returned in a very pleasant manner. Dr. Steffani Tiomno was very pleasant and VERY through! Answered all my questions and did not hurry me out. Great visit!
    1 month ago
    - Cindy B.
    This place is very nice and professional. Everyone is so friendly. I took my 10 months old baby there and I felt very comfortable with a treatment she received. The doctor was very patience, tried to keep my baby calm the whole time, and answered all our questions with no rush. I highly recommend this place.
    1 month ago
    - Natália B.
    Before I went to FAMILY EYE CARE I visited three eye dr in which 1 of the best 10 dr in USA . They weren’t able to solved my double vision problem. This dr solved my problem so they are god for me and I strongly recommend that others should visit this dr office. Staff members are so helpful and cooperative. Thank you very much dr STEFFANI TIOMNO.
    1 month ago
    - Jagdish P.


    Our office offers eye care services in Old Bridge, NJ and it’s surrounding areas.

    Dr. Moshe Roth specializes in Vision Therapy and Orthokeratology, and with nearly 30 years experience as a board certified optometric physician, he treats patients of all ages of their vision related problems. A wide range of professionals refer their patients with visual processing problems or learning disabilities to Dr. Roth due to his expertise.  Contact Us.


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    Online Patient Registration Form

    What is Astigmatism?

    Astigmatism can be confusing.  It is mistakenly called “stigmatism,” or "stigma".  This common vision problem can be corrected with eyeglasses, contact lenses or Ortho-K.  Like nearsightedness and farsightedness, astigmatism is a type of refractive condition related to the shape and size of the eye that causes blurred vision.  Astigmatism is a relatively common vision problem, but not too difficult to address.  Many people are relieved to learn that astigmatism is not an eye disease.

    Uncorrected astigmatism can cause blurred vision, headaches, eyestrain and make objects at all distances appear distorted.  Lenses for astigmatism can be made in several different ways:

    • Soft Toric - these have the advantage of comfort but may not be as sharp as Gas Permeable lenses
    • Oxygen Breathing / Gas Permeable - these often provide the best correction and more clear vision for astigmatism
    • Synergeyes Hybrid contact lenses have a GP center and a soft periphery (outside part) to provide the clarity of gas permeable lenses and wearing comfort that is comparable to soft lenses.
    • Orthokeratology