Find us at the corner of Barker Cypress & Cypress North Houston

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(832) 662-5936

Patient Registration Form

Thanks for contacting us! We will get in touch with you shortly.

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name
Address *
*

Personal Information

Gender *
Date of Birth *
*
*
Spouse/Parent’s Name

Medical Insurance*

Medical Insurance *

Vision Insurance*

Vision Insurance *
File must be 2MB or less
File must be 2MB or less

Medical History

Date of Last Physical Check-Up
Do you use
Females
Are you allergic to any medications? *
List name of medications including eye drops, vitamins, & birth control pills: dosages and frequency.
Have you ever been diagnosed or treated for the following health problems?
Have you had a concussion? *
What was the date of your concussion?

Eye History

Date of Last Eye Exam?*
Have you had any eye-related surgeries of any kind?
Are you currently experiencing, have been diagnosed with, or treated for any of the following?​​​​​​​

Family Medical/Eye History

Adopted?
Do you have a family medical history of any of the following?
Blindness
Cataracts
Corneal Problems
Retinal Problems
Glaucoma
Lazy/Crossed Eyes
Macular Degeneration
Diabetes
Heart Disease
Cancer

Privacy Policy

Health Information Protection *