Medical Plaza

Panther Creek

New Patient Form - Panther Creek


Title * First * Last MI Suffix Nickname
* Address:
* City:
  * State:    * ZipCode: 
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN * Email
* Birthday Occupation
Sex Male Female Employment Status Employed
Full-Time Student
Part-Time Student
Marital Status Employer/School Name
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
City State ZipCode
Home Phone:
Work Phone:


Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
City: State: Zip:
Phone Number:


Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
City: State: Zip:
Phone Number:


Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
City: State: Zip:
Phone Number:

Medical History


Referred by:
Family Members:
Last Eye Doctor/Phone:
Family Doctor/Phone:
Pharmacy Name:
Pharmacy Number:
* Race:
* Preferred Language:
* Ethnicity:
* Gender:
Social History (required for insurance)

* Do you smoke? 
Have you been infected with: HIV    Herpes Simplex    Hepatitis

* Ft. * In.
* Lbs.
Have you ever had any surgeries?

REVIEW OF SYSTEMS (required for insurance) Place check beside the following that apply or mark NONE below:

Constitutional (fever, weight gain/loss)
Ear/Nose/Throat (Hearing loss, Sinus)
Neurological (migraines)
Endocrine (thyroid, diabetic)
Respiratory/Pulmonary (asthma, bronchitis)
Cardiovascular, Vascular (Blood Pressure, cholesterol)
Gastrointestinal (colitis, crohns disease)
Genitourinary (bladder, prostate)
Bones/Joints(joint pain, rheumatoid arthritis)
Lymphatic/Hematologic (anemia, bleeding)
Allergic/Immunologic (sjogrens)
Psychiatric (depression)


* Are you allergic to any medications?

Please list:
List all current medications:

Please check if any of the following pertain to you:

Pulmonary Disease    Asthma    Diabetes    Hypertension    COPD    Heart Problems

* Are you Pregnant or nursing?   NO    Yes


Do you feel that your general health is:   Good    Poor    Fair

Family Medical History: Cancer Hypertension Arthritis Asthma Diabetes COPD

Eye History

Eye History (Are you experiencing any of the following symptoms?

* Please check all that apply.
Double Vision
Blurred Vision
Light Sensitivity
Eye Lid Itch
Foreign Body Sensation
Eye Pain
Droopy Eyelid(s)
Eyeball Itch
Variable Vision
Sting, Burn
Loss of Lashes
Distorted Vision

Have you had any eye surgery, laser treatments or eye injury?
No    Yes
If yes, please explain:

* Have You been diagnosed with Diabetes?
Yes No Type 1 Type 2 Pre - Diabetes
Have you been prescribed eye drops?
No    Yes

If yes, what drops and how often:

* Do you wear prescription glasses?
Yes NO
When do you wear your glasses?
All the time    Computer    Reading/Near     Distance Only


How old is this prescription?

Do you see well with this prescription?
No    Yes

Do you wear contacts? If so what brand:

* Right Eye RX:
* Left Eye RX:

Are you interested in contacts? No    Yes

What type of glasses would you like and for what types of activities:


Do you or a blood relative have:

Self Relative
Glaucoma NO   Yes NO   Yes
Cataracts NO   Yes NO   Yes
Lazy Eye NO   Yes NO   Yes
Retinal Disease NO   Yes NO   Yes
Macular Degeneration NO   Yes NO   Yes
Corneal Disease NO   Yes NO   Yes


Optomap Information As part of your annual eye examination, our doctors will assess the health of the anatomical structures at the back of the eye including your optic nerve, macula, blood vessels, and other various retinal tissues. This portion of the examination is critical in detecting vision problems, diagnosing ocular diseases such as glaucoma and macular degeneration, as well as screening for systemic health conditions such as diabetes and high blood pressure. There are two primary methods we utilize to evaluate your retinal health, as outlined below.

•  Standard Dilation - Drops are instilled into your eyes that (over a period of 20-30 minutes) will dilate the pupils and allow the doctor to view your retina with a series of lenses. Although the doctor can only see a small portion of the retina at any given moment, an evaluation of the entire retina is possible utilizing various lenses and eye positions. Side effects of the dilation drops typically include light sensitivity, and blurred vision for 4-6 hours following the dilation.

•  Optomap Imaging - The "optomap" is a widefield retinal imaging system designed to provide you and your doctor with archivable images of your retinal structures. The optomap requires no dilation drops to obtain the images, takes only seconds to perform, and the results are instantaneous. When you choose optomap as a part of your eye examination, your doctor will review your retinal health with you in the exam room, and we will maintain your widefield retinal photos in our database to serve as a basis of comparison for years to come: this means earlier detection of ocular health complications than would otherwise be possible without this technology. For these reasons, Optomap is the preferred option for all of our patients. However, please be aware that Optomap imaging may not be a covered service under some vision insurance plans.

* Medical Ocular Diagnosis: We will dilate and take enhanced Optomap Images and file to your medical insurance carrier.

Policies and Consents

Thank you for choosing Woodlands Eye Associates for your eye health needs. We would like to take this moment to discuss our financial policies and consents. HIPAA Consent to Use or Disclose Health Information For Treatment, Payment, and Healthcare Operations
In the course of providing health care to you, we may need to create, receive, and/or store health information
that potentially identifies you. It is often necessary to use and disclose this health information
in order to treat you, to obtain payment for services, and to conduct healthcare
operations involving our office. A comprehensive "Notice of Privacy Practices" is
available from our office that describes in detail the use and disclosure of such health
information. You are free to refer to this notice at any time before you sign this consent
document. As described in our "Notice of Privacy Practices" the use and disclosure of
your health information is necessary for you to receive ongoing care from this office or
in conjunction with other health professionals. Our "Notice of Privacy Practices" will be
updated when our privacy practices changes. Whenever our practices change you may
obtain an updated copy from our offices, or from our website at When you sign this consent form, you agree to the use and
disclosure of your health information to treat you, to obtain payment for our services,
and to perform healthcare operations.

Insurance Consent I hereby consent to the release of medical information (self,
child/dependent, or family member) to the insurance companies responsible for my
care. I understand that while my medical records are confidential, information within
these records may be required by my insurance company in order to facilitate care, and
will only be released at their request. I understand that by signing this consent form, I
am allowing my medical information to be released upon my insurance company's
request, for the purpose of healthcare operations (including but not limited to, provider
review function, claims payments, and quality assessment).

Insurance Services - Woodlands Eye Associates is in network as preferred providers
with many medical health plans and vision discount plans. Woodlands Eye Associates
will make every effort to verify coverage and benefits prior to your visit with the
physician. If we are unable to verify benefits, we will ask you to pay in full or
reschedule your visit until the verification can be obtained
. This verification will be
used to estimate your financial responsibility; however, this verification is not a
guarantee by your health plan of coverage or payment. If your health plan denies any
part (or the entirety of your claim), you agree that you are financially responsible for the

Medical Insurance - Medicare, United Health Care, Blue Cross, Aetna, Cigna, etc.
We bill medical insurance when you present a medical related complaint such as: itch,
burn, dryness, redness, eye pain, etc. that may or may not require treatment and
monitoring. We will also bill your medical insurance carrier for medical
diagnosis/findings such as Diabetes, Glaucoma, Cataracts, Floaters, Macular
Degeneration, etc. HMO Policies: We will help assist you in obtaining a referral
authorization from your Primary Care Physician (PCP) by faxing the detailed
information required for your visit. If we cannot obtain an authorization/referral for your
visit, you will be billed for the services rendered. Reminder: If you have not established
care with your designated Primary Care Physician (PCP) for your HMO medical
insurance, you may be required to schedule an appointment with your Primary Care
Physician (PCP) prior to authorizing referrals. Primary Care Physicians (PCP) may have
their own policies in place to issue referrals for services.
  • If you present with both a vision complaint and a medical complaint, we will
    bill to the appropriate insurance as indicated in your insurance by-laws.

  • Medicare Notice - We are Medicare participating providers; therefore, we will bill
    Medicare directly. However, as with any insurance carrier, you will be responsible at the
    time of services for payment of:
  • The annual deductibles

  • Co-payments

  • Charges for non-covered services: Example: $39.00 Refraction fee (may not be
    covered by Medicare supplement plan and/or vision discount plan).

  • A refraction is required to determine your best corrected vision. We will conduct
    refraction whether you wear glasses or not.

    You will also be asked to sign an Advanced Beneficiary Notice (ABN) form in the
    event a service is provided, which we know is not covered by Medicare or your
    supplemental insurance.

    Important: Please let us know if you signed up for a Medicare Advantage Plan.
    Traditional Medicare and Medicare Advantage Plans are not the same. If you
    signed up with a Medicare Advantage Plan, you no longer have traditional

    Vision/Routine Insurance - VSP, Superior, Eyemed, Spectera, etc. These discount
    plans are billed for routine eye exams, glasses or contacts lenses. They do not cover
    medical related complaints or conditions. Most vision discount plans require an
    authorization before your services are rendered. If we cannot obtain an authorization,
    you will be responsible to pay for both professional services as well as eye wear

    Private Pay Patients - We will provide you with itemized receipts for all transactions if
    you chose to file your own claim to your insurance carrier.

    Contact Lens Policy - (only applicable for patients desiring contact lenses) All contact
    lenses are "medical devices" according to federal law, and as such, require a proper
    fitting (in addition to the routine examination) to ensure ocular health. For patients who
    would like to be fit with contact lenses, the doctor performs a comprehensive eye exam
    to check the overall health of your eyes, as well as additional testing to assess the fit,
    prescription, and type of contact lens that best suits your eyes. The contact lens fitting
    fee ranges from $69.00 on up depending on the complexity of your prescription
    This fee includes trial contact lenses for the purpose of prescription changes
    and follow-up visit(s) when needed. Fees that are paid for examinations, contact lens
    evaluation/fitting, and progress checks for contacts lenses are non-refundable. If you
    are brand new to contacts, a one-time fee of $49.00 is charged for a Contact Lens
    Training in our office.
    A period of 60 days is allotted for all contact lens follow-up
    visits. A separate charge for any additional visits past the 60-day time frame may apply.
    Your prescription will be finalized once the doctor has determined an appropriate and
    healthy lens that you are satisfied with, and you have expressed to us that you would
    like to proceed with an order. Contact Lens Exams are required annually along with
    a Comprehensive Eye Exam. A contact lens prescription is valid for 1 year.

    Payment- Payment of copays, deductibles, coinsurance, out of pocket or non-covered
    services are due upon check out. We always obtain the most accurate amounts due
    from your insurance carrier. We will issue a refund or bill your account once we receive
    your explanation of benefits (EOB) from your insurance carrier. You will receive a
    detailed statement in the mail regarding your portion of the bill.

    Payment Methods - For your convenience we accept cash, pre-printed NON temporary
    checks, Visa, MasterCard, American Express, Care Credit, Discover, Flex
    Spending/HSA accounts and online bill pay as a form of payment.

    Claim Denials - Please be aware that certain office products, procedures or services
    may not be covered, or may be considered not medically necessary by your health plan.
    You are responsible for payment of these services. Such procedures and products
    include but are not limited to: contact lens fittings, specialty
    contact lenses, specialty eye glass lenses and designer frames, glaucoma scans, visual fields or other medically
    necessary testing. You will be billed if we obtain a denial from your insurance company
    and/or we have not received payment from the insurance company within 60 days of
    our filing your claim.

    Past Due Accounts - If your account becomes past due, we will take necessary steps
    to collect this debt. We are here to help.

    We encourage you to contact our insurance specialists to discuss your bill as needed.

    Medical Plaza Office Location:    Christina
                                                                  Office Phone: 281-367-2020
    Panther Creek Office Location:    Mollie
                                                                  Office Phone: 281-367-5335
  • Our insurance specialists are available Monday-Friday 8:30-5:00pm. If they are
       unavailable to take your call, please leave a detailed message and they will
       return your call within the next business day.

  • NSF Checks - There will be a $25 service fee charged to your account if your check is
    returned by your bank for any reason. Upon notification from our office of your returned
    check, payment of the entire balance is due immediately. We will accept payment in the
    form of credit card, cash, or money order.
    Photo & Social Media Woodlands Eye Associates uses a variety of resources
    to publicize events, products, and services. Should you object to a photograph or other
    electronic image of you or your child on social media, the company website, marketing
    brochures, publications, newsletters, or other media coverage prepared for use both
    inside and/or outside Woodlands Eye Associates, please notify our office. We would
    love for you to share your experiences at Woodlands Eye Associates with your family
    and friends!

    *I have read and agree to the policies and consents outlined above.
    Patient Signature:

    Submit Data

    When you have completed all of the forms, click the "Submit Data" button below: