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Bordering Cedar Park & North Austin, minutes from Lakeline Mall. NW Corner of El Salido Pkwy & 620, behind the Capital One Bank Building.

Call 512-918-EYES(3937) Schedule an Eye Exam Pay My Bill
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Online Patient Forms


Demographics

TitleFirstLastMISuffixNickname
Address: Apt/Suite #:
City: State: ZipCode:


Email: Cell Phone:
Preferred Contact Method:
 
SSN: Sex:
Birthday: Occupation:

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
AddressApt/Suite #
CityStateZipCode
Home Phone:
Work Phone:

Medical Insurance

Insurance Information Please select from the following Medical Insurance plans:
Insurance Name:
Insurance ID:
Insurance Policy Group:

Not Primary on Account:
Primary on Account
Name:Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
DOB:
Employer/School:

Vision Insurance

Insurance Information Please select from the following Vision Insurance plans:
Insurance Name:
Insurance ID:
Insurance Policy Group:

Not Primary on Account:
Primary on Account
Name:Last, First MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
DOB:
Employer/School:

Medical History

Last Eye Doctor:
Primary Care Physician:
Preferred Pharmacy
Medications (including OTC): - No current medications
Allergies: - No Known Drug Allergies
Preferred Language
Smoking Status
Do Your Eyes Sting, Burn, Itch, Or Feel Dry?
Have You Had An Eye Injury Or Been Diagnosed With Cataracts, Lazy Eye, Retinal Problems, Or Glaucoma?
Do You Have a History Of Headaches? Arthritis? Asthma? Diabetes? High Blood Pressure?
Heart Problems? Inflammatory Bowel Disease? Seizures? Thyroid Problems?
Do You Smoke? Are You Pregnant? Are You Nursing? Are You HIV+?
If Yes, Please List Below.
Does Anyone In Your Family Have/Had Diabetes? Lupus? Cancer? High Blood Pressure? Heart Problems? Auto-Immune Disease?
If Yes, Please List Below.
Does Anyone In Your Family Have/Had Glaucoma? Macular Degeneration? Retinal Detachment? Other Retinal Disorders?
If Yes, Please List Below.
Any Other Relevant Information?


Reading Symptoms



If yes, age when first worn:


If yes, age when first worn:


Glasses worn:
If yes, hours per day:




COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine?


Submit Data / Patient Signatures



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

Patient Signature: Date:

Call 512-918-EYES(3937) Schedule an Eye Exam Pay My Bill