If you do not yet have an appointment, please call our office at (713) 664-4760 or use our online
Appointment Request Form to schedule an appointment before submitting your information to us.

Responsible party
If the patient is the responsible party (skip this section).
If the patient is not the responsible party (complete this section).

Please list two people who could be notified in case of an emergency

Please list all insurances below, both vision and medical.
Also, please remember to bring all insurance cards with you to your appointment so that we can make a copy of them.
The social security number of the Policyholder is not a requirement for the completion of this form, but we will be unable to verify your insurance coverage without it. This form uses the highest level of security available on the web, but if you would rather give it to us by phone, call us at (713) 664-4760 and ask for the appointment desk.

Although our main focus is on your eyes (no pun intended!), your eyes are a part of your entire body. Your lifestyle, eyhnic origin, health problems that you may have, and medications that you may be taking -- including OTC, vitamins, and holistic / herbal preparations -- can have an important inter-relationship with the condition of your eyes and your prescribed eye care.

We want to give you the best eye care available, so we thank you for answering the following questions. Your answers are for our records only and are confidential.

General Health
Please list everything that you are currently taking. Include prescription, non prescription (over-the-counter), aspirin, vitamin supplements and holistic or herbal preparations.
-- or --

Not taking anything. Tell us if you have any allergies (such as latex, pollen, drugs, food, food additives or insect stings).

-- or --

No known allergies. Describe the purpose of this appointment.

-- or --

The purpose of this appointment is a routine eye exam.

Eye Health I

Contact Lenses:

Answer questions (a) through (f) below only if you currently wear contact lenses.

Eye Health III

(Your email address is never shared with anyone else. It will be used only for the purposes listed above.)

Please scroll up and review your responses before submitting this information.

Thank you for choosing us for your eye care. We look forward to seeing you!