Online Form

Online Forms

If you do not yet have an appointment, please call our office at 713-664-4760 or use our online Appointment Request Form to schedule an appointment before submitting your information to us.

Patient Information

Last Name:

First Name:

MI:

Title:

Appointment Date:

Gender:

What is your 'nickname', or by what name do you prefer to be called?

Address:

City:

Select State:

Zip:

Social Security #:

D.L.#:

Driver's Lic. State:

Personal Phone:

Daytime Phone:

Ext.#:

Email:

Retype Email:

Occupation:

Employer:

Address:

How Long?:

Student:

If Yes - City:

If Yes - State:

Name of nearest relative not at the same address:

Relationship:

Address:

City:

State/Country:

Phone:

Marital Status:

Responsible Party

Last Name:

First Name:

MI:

Title:

Address:

City:

Select State:

Zip:

Date of Birth:

Age:

Social Security #:

D.L.#:

Driver's Lic. State:

Personal Phone:

Daytime Phone:

Ext.#:

Email:

Retype Email:

Occupation:

Employer:

Address:

How Long?:

Name of nearest relative not at the same address:

Relationship:

Address:

City:

State/Country:

Phone:

Relationship to the patient?

Please state relationship if 'other'

How were you referred to us?

Name:

City:

Phone:

Please list all insurances below, both vision and medical.

Also, please remember to bring all insurance cards with you to your appointment so that we can make a copy of them.

The social security number of the Policyholder is not a requirement for the completion of this form, but we will be unable to verify your insurance coverage without it. This form uses the highest level of security available on the web, but if you would rather give it to us by phone, call us at 713-664-4760 and ask for the appointment desk.

Primary Insurance Information

Insurance Company Name:

Address:

City:

State:

Phone Number listed on card for verification of benefit eligibility:

Name of Insured (Policyholder):

ID / Policy / Subscriber Number:

Group or Employer Name:

Group Number:

Policyholder's D.O.B.:

Soc Sec# of Insured (Policyholder):

Patient's Relation to Insured:

Secondary Insurance Information

Insurance Company Name:

Address:

City:

State:

Phone Number listed on card for verification of benefit eligibility:

Name of Insured (Policyholder):

ID / Policy / Subscriber Number:

Group or Employer Name:

Group Number:

Policyholder's D.O.B.:

Soc Sec# of Insured (Policyholder):

Patient's Relation to Insured:


Although our main focus is on your eyes, your eyes are a part of your entire body. Your lifestyle, ethnic origin, health problems that you may have, and medications that you may be taking -- including OTC, vitamins, and holistic/herbal preparations -- can have an important inter-relationship with the condition of your eyes and your prescribed eye care.

We want to give you the best eye care available, so we thank you for answering the following questions. Your answers are for our records only and are confidential.
​​​​​​​

General Health

Please list everything that you are currently taking. Include prescription, non-prescription (over-the-counter), aspirin, vitamin supplements, and holistic or herbal preparations.
-- or --

Tell us if you have any allergies (such as latex, pollen, drugs, food, food additives, or insect stings).
​​​​​​-- or --​​​​​​​

Describe the purpose of this appointment..
​​​​​​​​​​​​​​-- or --​​​​​​​

Are you currently under the care of a physician?

If 'Yes' Physician's Name:

Phone:

What was the approximate date of your last physical exam?

Name of Physician:

City:

Select State:

Phone:

What is your ethnicity?

Do you drink alcohol?

Do you smoke?

Do you exercise?

What types of exercise?

Eye Health I

Do you currently wear glasses?

What type of glasses do you own?

Do you use a Computer?

Approx. Hours per day:

Approx. distance from computer: ( inches )

Please describe any problems that you are having with your eyeglasses.

Eye Health II

Please check all below that apply to you. Checked boxes indicate that the answer is 'Yes'

Do you suffer from any of the following? Please check all that apply.

Contact Lenses:

Do you currently wear contact lenses?

How long have you been wearing contacts?

Have you ever tried wearing contact lenses and stopped?

If you answered 'Yes' above, what was your reason for stopping?

Are you interested in using contact lenses to change or enhance your eye color?

If you wear contact lenses, do your backup eyeglasses have your correct prescription?

Answer questions (a) through (f) below only if you currently wear contact lenses

A. What type or brand of contacts do you wear?

B. ​​​​​​​How old are your current lenses?

C. How often do you replace or dispose of your contact lenses?

D. What brand of solution do your lenses soak in overnight?

E. What is your typical wearing schedule?

F. Please describe any problems you are having with your contact lenses.

Eye Health III

Have you ever had an injury to either of your eyes? If you checked 'Yes', please use the text box to tell us about it.

If you have ever had any type of eye surgery, please give us the information below.

Type of surgery:

Month and Year:

Doctor:

Phone:

Type of surgery:

Month and Year:

Doctor:

Phone:

What was the approximate month and year of your last eye exam?

Where did you get the exam?

Use this space for additional comments or information -- or if you have a specific issue concerning your eye health that you want to discuss with the doctor when you come in for your appointment.

Do you have a hobby or special interest? What do you like to do in your spare time?

We like to keep you informed -- and we enjoy remembering you on special occasions:
May we email you approximately twice yearly to inform you of the latest news in the area of eye health?

May we send you seasonal and birthday greetings via email?


​​​​​​​
(Your email address is never shared with anyone else. It will be used only for the purposes listed above.)

Please scroll up and review your responses before submitting this information.
Thank you for choosing us for your eye care. We look forward to seeing you!
​​​​​​​

Contact Info

  • Address:
    4760 Beechnut St.
    Houston, TX 77096
    Get Directions
  • Phone:
    (713) 664-4760
Connect:
/*|--------------------------------------------------------------------------| LANDING PAGE|--------------------------------------------------------------------------*/ https://s3.amazonaws.com/static.organiclead.com/Site-92911c49-4382-4897-a09b-4b18899f8ba3/general_landing_ppc/BG_Hero.jpgContact UsIf you wish to learn more about our services, contact us today!Focused On Your Vision NeedsComprehensive Eye Exams & Contact Lens Fittings

At Houston Dry Eye Clinic, we’re committed to providing personalized eye care with a focus on your comfort and clarity. Whether you're due for a routine eye exam or exploring your options for contact lenses, our experienced team is here to help.

Our ServicesClear Vision Starts with the Right Carehttps://s3.amazonaws.com/static.organiclead.com/Site-92911c49-4382-4897-a09b-4b18899f8ba3/general_landing_ppc/srvcs_comprehensiveeyeexam.jpghttps://s3.amazonaws.com/static.organiclead.com/Site-92911c49-4382-4897-a09b-4b18899f8ba3/general_landing_ppc/srvcs_contactlens.jpghttps://s3.amazonaws.com/static.organiclead.com/Site-92911c49-4382-4897-a09b-4b18899f8ba3/general_landing_ppc/srvcs_patientexperiences.jpg Comprehensive Eye ExamsContact Lens FittingsScleral Lenses https://s3.amazonaws.com/static.organiclead.com/Site-92911c49-4382-4897-a09b-4b18899f8ba3/general_landing_ppc/bg_appointment.jpg #25aae1#0e76bc