Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the Submit button in the 'Submit Data' tab. If you have any questions, please call us at 830-625-2845. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

*City: *State: *Zip Code:
*Home Phone: Work Phone:
Other Phone:
*Cell Phone: Preferred Contact Method:
SSN *Email
*Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Billing Information

Is The Billing Address Different?
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

*Problem/Reason of Visit *Last Eye Exam:
*Allergies (Type None If None): *Systemic Meds/Vitamins (Type None If None):
*Ocular Meds:

Patient Visual Symptoms (Check All That Apply)

No Complaint Head Aches
Blur At Distance Watery Eye Glare
Blur At Near Floaters Eye Infection
Itchy Eye Flashes Eye Injury
Dry / Burning Eye Double Vision Temporary Vision Loss


*Do You Currently Experience? (Check Atleast One Checkbox Below)

GEN: Fever, wt loss, wt gain, fatigue?
ENT: Allergies, Sinus, Cough, Dry ENT
CARDIO: High BP, Heart, Vasc Dz
RESPIR: Asthma, Bronchitis, Emphysema
GI: Diarrhea, Constipation, Ulcer, Reflux
REPRO/URINARY: Infection, Inflam, Pain
MM, BONES, JOINTS: Arthritis, Injury
SKIN: Growths, Acne
NEURO: HA, Numb, Dizzy, Seizures
PSYCH: Depress, Anxiety, Insomnia
BLOOD: Anemia, chol, bleed
IMMUN: Rheum, HIV/AIDS, Lupus
Pregnancy or nursing
ENDO: Thyroid, Diabetes
N/A (Not Applicable)
If you check any of the above boxes, please specify here:

Social History

Occupation: Employer:

Submit Form / Patient Signature

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

View Notice of Privacy Practices Form

*I have read and agree to the Privacy Policy.   *Patient / Guardian Signature: *Date: