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New Patient Information Forms

What To Do



Hi, and welcome to Optimal Eye Care!

These pages have been designed to collect all the information necessary before Dr. Rhea can examine your eyes, evaluate your vision needs, or prescribe spectacles or contact lenses.

Please complete all the forms with all the appropriate information before you come in for your appointment.

When you finish, you must go to the "Save and Exit" tab and press the "Submit Data" button. If you don't press the Submit Data button before closing your browser window all the information you entered will be lost.

When you come in for your appointment, please be sure and bring your driver's license or other ID and your insurance card(s) as we will need to copy each of these for our records.

If you don't yet have an appointment, after pressing the "Submit Data" button, you can request an appointment at a time and date convenient for you by pressing the white "Request Appointment" button on the upper left of most Optimal Eye Care webpages.

Thanks for choosing Optimal Eye Care!

Demographics

TitleFirstLastMISuffixNickname
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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Ins

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Ins

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary Ins

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Save and Exit



Please be sure to press the "Submit Data" button before closing your browser window or all your hard work will be lost!








After completing all forms please be sure to press "Submit Data" on the rightmost "Save and Exit" tab or all the information you entered will be lost.

Optimal Eye Care, P.C.,
2945 Gulf Freeway South Suite C,
League City, Texas 77573-6771 Phone 281.309.9700   Fax  281.309.9720
Content copyright 2011 - 2012. Optimal Eye Care, P.C. All rights reserved.