Established Patients

Welcome Back!

Inquiries regarding the website should be directed to

Reason For Visit

Click to Expand
What is the reason for your appointment with us?
Please Print, Fill Out & Bring this form to your appointment.



Patient Portal

Click to Expand


Update your medical history through our Patient Portal prior to your visit.

If you have accessed your Patient Portal previously, update your information (or reset your password) here:

Patient Information & History:
After you have your username and password for our patient portal, 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 CANNOT 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:








For first time activation submit this form:


Trouble accessing your Patient Portal? Contact

Insurance Authorization

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

It is your responsibility to contact your insurance carrier regarding your benefits and to ensure 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.




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 started immediately, as 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 Registration at 215-928-3105 or
If you come to Shields & Shields without your authorization or referral you will be considered self pay.
We do not accept personal checks.


Physical Exam

Click to Expand

Getting surgery? You will need a physical. Please have your physician fill out the Physical Evaluation form. 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.



Insurance CPT Codes

Click to Expand

You’re Complete!

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

Are You A Conjunctival Melanoma Patient?

Since your initial diagnosis of conjunctival melanoma, research has shown that there are special mutations (changes in DNA) that can occur in the cancer cells. If these mutations are detected, there are certain medications that can be used in the treatment of metastasis (spread to other places in the body).

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.