Patient First & Last Name:
Patient DOB:
Guarantor First & Last Name (if different than above):
Address (city, state, zip):
E-mail:
Cell Phone:
Patient Occupation or Grade Level:
Parent or Spouse Name:
What is the major purpose of this visit?
Whom may we thank for referring you?
If not referred, how did you hear about us?
Vision & Medical Insurance Companies (Please enter your Vision and Medical Insurance Companies' names. During the course of a yearly eye exam, there may be concerns that require that we bill your medical insurance in order to help you utilize the proper insurance benefits for the services provided.)
Vision Insurance I.D. Number: (this is used for ONLY for eyeglasses and contacts prescriptions)
Suscriber's Name:
Subscriber's DOB:
Subscriber's Last 4 of S.S. #:
Vision Insurance Company's Phone:
Medical Insurance I.D.: (this is used for checking red eyes, painful eyes, glaucoma, diabetes and any other medically-related health concern)
Medical Insurance Company Phone:
Subscriber's Name & DOB (if different than for Vision Insurance):
By entering my name below, I understand & agree with the Insurance & Fee Responsibility Agreement (see link at the bottom of the page to review Agreement)
Date I signed Insurance & Fee Responsibility Agreement
Name & Phone Number of Primary Care Physician/Pediatrician
Preferred Pharmacy (e.g. HEB Missouri City)
Date of Last Physical with Blood Work-up
List of Current Medications (if none, type "none"; include vitamins)
Allergies (if none, type "none"; include medicines, foods, seasonal)
List major surgeries, hospitalizations (if none, type "none")
Please elaborate on conditions selected above or any other conditions not listed:
Date of your last eye exam (if never, type "none")
Name of previous eye doctor (if none, type "none")
Which contact lens cleaning solution do you use?
What contact lens brand do you wear?
How many hours per day do you wear your contacts?
By entering my name below, I agree with the Notice of Privacy Practices (see link at the bottom of the page to review Privacy Notice)
COVID-19 Release: Even with increased safety measures, there is an inherent risk of being exposed to COVID-19 whenever you are in a public place and people are present. COVID-19 can lead to severe illness and death. By visiting the office, you assume all risks associated with exposure to COVID-19. By entering my name below, I agree (if the patient is a minor, please have a parent or guardian sign off on this COVID-19 Release).
Date that I signed and consented to the COVID-19 Release as stated directly above: