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Located 2 doors down from Dunkin Donuts on Union Valley Rd

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Home » Patient Info Sheet

Patient Info Sheet

  • Visual Information

  • Lifestyle Factors

  • (eye strain/tilt your head)
  • Contact Lens Rating

  • 1 being poor, 5 being excellent
  • 1 being poor, 5 being excellent
  • Health Information

  • Do you or anyone in your family have a history of:
    (please check all that apply)
  • (please check all that apply)
  • MedicationDosage 

  • NOTE: Your insurance plan is a contract between you and your insurance company. Our office cannot be responsible for determining your benefits. You must notify us if your insurance plan covers routine vision prior to any services. If you are not sure if your plan covers routine vision, payment is due at the time services are rendered. If your plan requires a referral, it is your responsibility to obtain one from your primary care doctor prior to your appointment. If your insurance denies the charges incurred, they are your responsibility.

    Assignment of Benefits: I hereby consent to such treatment and patient care, which may be considered necessary or advisable as a patient of Adriana Palumbo, OD for services rendered. I understand that I am ultimately responsible for all charges on services rendered, whether or not paid by insurance.

  • Date Format: MM slash DD slash YYYY
  • In case of divorced or separated parents, our policy is that the parent bringing the child into our office is responsible for payment of all fees.

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As our community copes with the fast-moving spread of the COVID-19 coronavirus we hope you and yours are in good health during these stressful times.

Public officials have asked businesses to close down for a limited time while a local quarantine begins. 

We will be available for eyecare emergencies by appointment. Please contact us at 973-728-1101 if you have any questions and we will respond back as quickly as we can. All other emergencies please call 911.

If you need to order contact lenses you can do so by going to our website and click on the contact lens order link on the left hand side of the screen.

When we are given the green-light to renew normal business operations we will update you. We thank you for your patience during this interruption and hope to see you when we re-open, happy and healthy.

West Milford Vision Center


Even though we are closed we are still available to serve our patients. We are just a phone call away!

If you have an eye emergency, please contact us- we’re here for you.

If you need to order contacts, please visit our website and do it online.

Finally, we can also help you with eyeglass repairs or replacements.