Patient Information

Are you new to this Practice? (check if YES)

Legal Name

Preferred Name (opt.)

DOB

Member ID

Sex
Sex Male Female Prefer not to answer
Contact Info


Is this your first appointment with us? (check if YES)

Insurance Policy Number

Insurance Provider


Insurance Plan

---

Appointment Date/Time

Provider:
Location:
Date and Time Requested:

---

Appointment Details

Appointment Reason Cataract Evalaluation Diabetic Eye Exam Lasik or Refractive Evaluation Glaucoma Evaluation Comprehensive Eye Exam Eyelid Surgery Evaluation Other (please use comment box)

---

Texting Consent:I wish to authorize DoctorConnect.net and the healthcare provider to send me appointment details and other important messages related to my healthcare via text message according to terms and conditions and our privacy policy. Standard data rates may apply. For Help text (972) 853-8554, Text STOP to unsubscribe

---

Send Appointment Request All Appointment Requests are Tentative & Subject to Office Approval