Online Patient Forms Demographics and Insurance Information Demographics and Insurance Information Cell PhoneWork PhoneDate of Birth Date Format: MM slash DD slash YYYY AgeSexMaleFemaleEmail SSNOccupationEmployerEmergency Contact First Last PhoneRelationship of Emergency Contact to PatientNew Patients Only: Name of doctor or referring party First Last Insurance InformationPrimary Insurance CarrierSecondary Insurance CarrierResponsible Party (if patient is a minor)To allow us to file for your medical insurance benefits and/or accept Medicare assignment, you will need to sign a release upon visiting the office. Please call us at (214) 522-2661 if you have any questions! Medical/Ocular History MEDICAL/OCULAR HISTORY Name First Last Date of Birth Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY Drug AllergiesSurgical HistoryCurrent MedicationsSmoking History*Current SmokerFormer SmokerNever SmokerMedical Conditions That Apply to You Arthritis Asthma Cholesterol Headaches Heart Disease High Blood Pressure HIV Lung Disease Rosacea Seasonal Allergies Seizures Shingles/Fever Blisters Stroke Thyroid Cancer Diabetes Other If Cancer was selected, please specify type:If Diabetes was selected, please provide most recent blood sugar count and date takenIf Other was selected, please specifyEye Conditions that Apply to You (past and present): Cataract Color Blindness Corneal Disease Diabetes Double Vision Dry Eye Glaucoma Lazy Eye Macular Degeneration Retinal Detachment or Tear OtherGlasses - How LongEye Surgery LASIK/PRK RK Cataract Glaucoma Retina Cornea Transplant Surgery DetailsEye/medical conditions of your immediate family: Cataracts Glaucoma Diabetes Blindness Macular Degeneration Cornea Any other type of ocular diseaseType of contact lenses you are wearing: Soft RGP Toric Multifocal Monovision How long to you wear one pair of contact lens: 1 Day 1-2 Weeks 1-2 Months Other Type of cleaning solutions usedAny allergies to contact lensAny problems with current lenses
