Meyerland New Patient Form

To save time before your visit you can fill the online Patient Form shown below.

Our office will contact you by phone or by email should we need have questions or need further information.

Insurance(*)

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Patiend Name(*)

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Gender

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Date of Birth

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Home #

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Mobile(*)

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Email(*)

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Home Address

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SSN

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City

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State

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Zip

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Driver’s License:

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Occupation

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Employer

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Medical History

Do you have any allergies to medications?

Yes

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If yes, which?

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Are you pregnant and/or nursing?

Yes

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List any medications you take: (include over the counter)

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Review of Systems Please tick the check boxes (as YES) if the any of the following applies to you

Do you drink more than 2-3 alcoholic drinks/day?

Yes

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Do you use tobacco products regularly?

Yes

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Do you use illegal drugs?

Yes

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Date of last physician visit

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Date of last eye exam

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Physician’s name w/ phone

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Previous Eye Doctor?

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Do you wear glasses?(*)

Yes

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How old is your current pair?

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Have you ever worn contacts?(*)

Yes

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How old is your present pair (contacts)?

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Contact lens brand:

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Type of contact lenses (Choose one)?

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Do you sleep in your lenses?

Yes

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Pupil Dilation

In order to examine the entire eye, we must dilate the pupil. Examining the eye is like trying to look into a room through a keyhole. By enlarging the pupil, the doctor is able to clearly see the areas within the eye. Gentler drops now provide the means for a quick, painless examination with minimal side effects. You may experience a temporary dryness of the eye, some blurring of near vision, and some light sensitivity for a period of three to five hours. Many types of eye disease and injury can go undetected without dilation. As with any disease, early diagnosis is essential to successful treatment and prevention of future complication.

May we have your permission to dilate your eyes?(*)

Yes

Will discuss with my doctor

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Electronic Consent(*)

I hereby authorize and consent to contents of this form as a Patient/Guardian

Invalid, please accept eSign to proceed with submission

AntiSpam(*)

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Pricing Table Particle

Eye Trends: Meyerland Plaza Patient Form

Medical History

Review of Systems Please tick the check boxes (as YES) if the any of the following applies to you

Pupil Dilation

Contact Details

Eye Trends Locations

Join Dr. Zaibaq's Newsletter

Pricing Table Particle

Eye Trends: Meyerland Plaza Patient Form

Medical History

Review of Systems Please tick the check boxes (as YES) if the any of the following applies to you

Social History This information is kept strictly confidential!

Pupil Dilation

Contact Details

Eye Trends Locations

Join Dr. Zaibaq's Newsletter