Eye Center of Houston

Patient Information

Name

First Last

Date of Birth

Age

Sex

Address

Street Address ZIP / Postal Code

Email

Home Phone

Cell Phone

SSN

Insurance

How will you be paying for your visit today?

Medical Insurance
Vision Insurance
Self Pay

Medical Insurance Company

Vision Insurance Company

Visual and Medical History

Reason for today's visit?

Glasses Exam
Contact Lens Exam
Red Eye(s)
Other

Will you be purchasing prescription glasses (or sunglasses) today?

Yes
No

Have you been to our office before?

Yes
No

Medications you are currently taking:

Are you allergic to any drugs? (If yes, please list)

Please check all that applies to you and/or your immediate family members?

Surgery or Other

Pregnant?

Yes
No

Nursing?

Yes
No

Tobacco Use?

Yes
No

How did you hear about us?

Family
Friend
Doctor
Billboard
Website
Walk-in
Other

If personally referred, whom may we thank for the referral?

All insurances must be presented at the time of service. Professional fees are non-refundable and non-negotiable. Payment must be collected at time service is rendered. For insurance patients, please be aware that you are fully responsible for the services not covered by your insurance plan.

Signature of Responsible Party and Consent to Treat:

YOU MUST READ AND SIGN THIS SECTION

Visual Field Screening: This screening checks for visual field defects, both in central and peripheral vision areas using the latest technology. Visual fields screening can assist in early detection of glaucoma, optic nerve disease, visual related neurological diseases, and possible cause of headaches. The fee for this screening is $20.00.

Visual Field Screening

I DO consent to having Visual Fields Screening performed.
I DO NOT consent to having Visual Fields Screening performed. I release my doctor from any liability of failure to treat or diagnose any eye condition due to the lack of diagnostic information that could have been obtained from this screening.

Pupil Dilation: Dilation enlarges the size of the pupils and allows the doctor a more thorough examination of the retina. This helps to detect many medical conditions such as diabetes, glaucoma, cataracts, hypertensive changes, retinal holes and detachments, and melanomas (tumors). Dilation is strongly recommended for all patients. After being dilated, you may experience blurred near vision and light sensitivity that can last from 3-6 hours.

There are no additional fees for dilation.

I DO consent to having my eyes dilated.
I DO NOT consent to having my eyes dilated. I release my doctor from any liability of failure to treat or diagnose any eye condition due to the lack of diagnostic information that could have been obtained from this procedure.

Patient's Signature or Signature of Patient's Legal Representative*

Date*

HIPAA PRIVACY

I understand that the Eye Center of Houston may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information, and/or type of products provided) to another party to permit to perform its administrative duties, provide me with eye care services and products, process my medical and/or vision benefit claims and communicate with me regarding medical/vision care services provided. I can be assured that this location does not sell my personal health information of any kind to a third party for such party's own use. I authorize to submit my medical/vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the medical/vision services and products that I have received.

Patient signature or Patient's legal representative*

Date*