1170 N Preston Rd Ste 120 Prosper, TX 75078

Home
Patients
- Insurance and Payments
About Us
Eyecare Services
Blog
Contact Us
- Appointment Request
2025 Missions Trip

1170 N Preston Rd Ste 120 Prosper, TX 75078

Request an Appointment | (214) 305-4020

Home
Patients
- Insurance and Payments
About Us
Eyecare Services
Blog
Contact Us
- Appointment Request
2025 Missions Trip

Home

New Patient Health History Form

New Patient Health History Form

NEW PATIENT REGISTRATION

In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Contact Information

First Name / Last Name

Daytime Phone

Mobile Phone

Street Address / Suite/Apt. / City / State / Zip Code

Guardian Information (if patient is under 18 years of age)

First Name / Last Name

Daytime Phone

Mobile Phone

Street Address / Suite/Apt. / City / State / Zip Code

Patient Information

Gender

Date of Birth

Social Security No.

Primary Medical Insurance information

Provider Name

Provider Phone

Policy/I.D. No.

Group No.

Secondary Medical Insurance information

Provider Name

Provider Phone

Policy/I.D. No.

Group No.

Vision Insurance Information

Provider Name

Provider Phone

Policy/I.D. No.

Group No.

Financial Assignment Information

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Acknowledgment of Notice of Privacy Practices (NPP)

Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms. No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms. The NPP could not be read due to the emergent nature of the care needed.

PATIENT HISTORY

Vision Correction History (please check any that apply)

Amblyopia (lazy eye) Blurred vision at a distance Blurred vision at near Burning Double vision Drooping eyelid(s Dryness Eye pain and/or soreness Floaters or spots Fluctuating vision Foreign body sensation Halos I experience regular headaches I stopped wearing contact lenses I stopped wearing glasses Infection of eye or lid Itching Loss of peripheral vision Loss of vision Mucous discharge Redness Sandy or gritty feeling Sensitivity to light/glare Strabismus ( crossed eye ) Tired eyes Watery eyes

Glasses History ( check all that apply )

What glasses do you own?

Single vision distance Single vision near Bifocal Progressives Sunglasses Computer lens Other

If Other

How many hours per day do you spend using a computer?

What brand of contacts do you wear?

How old are your current contacts?

How often do you replace them?

What solution do you use for soaking?

What is your typical wearing schedule?

Check any that apply

I do not want to wear contacts Incorrect prescription Interested in non-surgical correction Interested in refractive laser surgery Need spare contacts Problems with current contacts Would like to change my eye color

Family Ocular History (check all that apply)

Macular Degeneration Glaucoma Blindness Other

PATIENT HISTORY

General Medical History (please answer appropriately)

When (approx.) was your last eye exam?

Primary care physician name

Primary care physician phone

Please list all eye conditions you have experienced:

Surgeries:

Do you have any of the following?

Arthritis Asthma Cancer Diabetes Heart disease High cholesterol HIV Hypertension (high blood pressure) Migraines/headaches Multiple sclerosis (MS) Other

If Other

Referral Information

How did you find out about our office?

Referred by your doctor Visited our website Facebook, Instagram Referred directly

Keep in touch

@Instagram handle

@Twitter handle

Questions and notes

Do you have a question? Concern? We want to know

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

HOURS

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 6:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 6:00 pm

Friday

9:00 am - 6:00 pm

Saturday

9:00 am - 3:00 pm

Sunday

Closed

Contact Us

Name*

Email *

Phone *

By providing your phone number by phone or online, you are consenting to receive SMS text messages from Prosper Eye Gallery. Msg & data rates may apply. You may reply STOP to opt out of messages.

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent and a staff member will be reaching out soon!

Error!

Our Location

--mi

Prosper Eye Gallery

Address

1170 N Preston Rd Ste 120
Prosper, TX 75078

Contact Information (214) 305-4020

Get Directions

1170 N Preston Rd Ste 120 Prosper, TX 75078
(214) 305-4020

Admin Log In
Site Map
Privacy Policy