Online Patient Form

Please fill out the following information accurrately and completely. Please leave unknown fields empty or enter N/A. If you do not have or are not planning to use insurance, you may skip those sections. If you need assistance, please call us at 972-378-0871.

After you are finished, remember to use the button at the bottom to submit your information. Thanks!

Demographics


Patient Information
TitleFirst NameLast NameMISuffixNickname
Address:
City: StateZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student
Part-Time Student
Marital Status Employer / School Name
Primary Optometrist
Is The Billing Information the Same?

TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Insurance Name:
Insurance ID:
Insurance Policy Group:

If you are not the primary subscriber, please click this checkbox and fill out the additional information below:
Patient is not primary subscriber
Primary subscriber information:
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Insurance Name:
Insurance ID:
Insurance Policy Group:

If you are not the primary subscriber, please click this checkbox and fill out the additional information below:
Patient is not primary subscriber
Primary subscriber information:
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Reason for visit
Last Eye Exam Primary vision correction
If you are a contact lens wearer, do you have a backup pair of glasses? Are you interested in new glasses?
Please list any eye diseases/conditions you currently have or have had:
Please list any medical conditions you currently have or have had:
Please list previous injuries, surgeries, or hospitalizations
Please list any significant medical conditions in the immediate family
Please list your current medications:
Drug Allergies: OTC medications: Pregnant Or Nursing:
Occupation: Hobbies:
Tobacco:Type: Frequency/duration:
Alcohol: Type: Frequency/duration:
Recreational Drugs: Type: Frequency/Duration:
STD:

SUBMIT FORM

When finished, please click the button below to submit your form. We look forward to your visit.