Dallas Eyeworks

7324 Gaston Ave. Ste. 310
Dallas, TX 75218
TEL:(214)660-9830. FAX: (214) 660-4511
www.dallaseyeworks.com

Please note that our front door is not accessible from Gaston Avenue. Please drive around the building, using either Tucker Street or East Grand Avenue and you will have the ability to park directly in front of our entrance.

Dear Patient:

We welcome you to our practice and ask that you kindly complete or correct all information on this form.

PATIENT INFORMATION

PATIENT NAME: SEX: SOCIAL SECURITY NUMBER:
ADDRESS: DATE OF BIRTH: MARITAL STATUS:
CITY, STATE & ZIP: EMAIL:
HOME PHONE: WORK PHONE: MOBILE PHONE:
EMPLOYER: OCCUPATION:
EMPLOYER’S ADDRESS: PRIMARY CARE PHYSICIAN:
EMPLOYER’S CITY, STATE & ZIP: PRIMARY CARE PHYSICIAN’S PHONE:
Do you or your family have any history of the following conditions (check all that apply)?:
Self
Family
Glaucoma
Cataracts
Diabetes
High Blood Pressure
Macular Degeneration
Heart Problems
Retinal Degeneration
Stroke
Thyroid Condition
Crossed/Lazy Eyes
Asthma/ Allergies
Color Blindness
Arthritis
Tuberculosis
HIV/Hepatitis
Cancer
High Cholesterol
Blindness
Other:
Do you currently have any of the following symptoms (check all that apply)?:
Blurry distance vision
Poor night vision
Eye Strain
Blurry Near Vision
Trouble Reading
Itchy Eyes
Discharge
Watering
Pain in the eye
Burning eyes
Sandy/dry eyes
Red Eyes
Glare/reflections
Discomfort in sunlight
Double vision
Floaters or spots in vision
Flashes of light
Eye injury
History of wearing an eye patch
History of eye surgery
Headaches
Dry Eyes
Are you interested in any of the following (check all that apply)?:
New Eyewear
Back-Up Glasses
Light weight glasses
Anti-reflective lens
Ortho K
Colored contact lens
Polarized Sunglasses
Vitamins
Safety glasses
Lasik
Contact lenses
Dry eye therapy
Myopia control
How were you referred to us?
Family doctor
Yellow Pages
Insurance company
Another patient:
Other:
MEDICATIONS:

ALLERGIES:

SOCIAL HISTORY:
Alcohol use
Drug use
Tobacco use
Other:

Dallas Eyeworks

7324 Gaston Ave. Ste. 310
Dallas, TX 75218
TEL:(214)660-9830. FAX: (214) 660-4511
www.dallaseyeworks.com

GUARANTOR

GUARANTOR NAME: GENDER: SOCIAL SECURITY NUMBER:
ADDRESS: DATE OF BIRTH:
CITY, STATE & ZIP: PATIENT’S RELATIONSHIP TO GUARANTOR:
HOME PHONE: WORK PHONE:

PRIMARY VISION INSURANCE

SECONDARY VISION INSURANCE

COMPANY NAME: COMPANY NAME:
POLICY ID NO.: POLICY ID NO.:
POLICY GROUP: POLICY GROUP:

PRIMARY MEDICAL INSURANCE

SECONDARY MEDICAL INSURANCE

COMPANY NAME: COMPANY NAME:
POLICY ID NO.: POLICY ID NO.:
POLICY GROUP: POLICY GROUP:

MEDICAL INSURANCE POLICY: As part of our services at this practice we are happy to assist you in determining the benefits of your individual policy and in collecting your reimbursement of insurance benefits for medical services. To avoid any misunderstandings please read the following statements carefully:

  1. The legal obligations of your insurance provider are between yourself and your provider, not between this practice and your provider.
  2. When your insurance provider (s) has settled your plan’s covered items, you will be notified by a monthly statement if there were any unpaid balances. Unpaid balances can include non-covered items or services, co-pays, deductibles, lapses, ineligibility or termination of coverage’s. Unpaid balances are the sole responsibility of the patient.
  3. To keep the cost of records and collections down any patient portion amounts on your order will be due at the time of service.
  4. I authorize the use of this form on all insurance submissions as well as authorizing the release of information to all my insurance companies as well as allowing the doctor to act as my agent to help me in obtaining payment from my insurance companies.
  5. I authorize payment to be made directly to the provider and permit a copy of this authorization to be used in place of the original.

REFUND/RETURN POLICIES: No refund can be made on clinical procedures or services, including comprehensive eye examination, refraction, contact lens fitting, and medical office visits. Refunds for optical products, which include frames, lenses, and unopened boxes of contact lenses can only be made within 30 days of receiving the product, provided that the product is returned to the store without damage at the time that the refund is issued. Opened boxes of contact lenses are non-refundable. After the 30 days period, only 50% of the original payment made by the patient (private-pay or with insurance) can be issued back to the patient as store credit with the return of the product. 90 days after a product is dispensed, no refund, no exchange, no return can be made on any goods purchased at this store.

CONSENT FOR TREATMENT: I hereby authorize Dallas Eyeworks to administer diagnostic and medical procedures as may be necessary for proper health care.

Signature of patient or authorized representative
Date
Name of Patient: Authorized representative’s name