Name: Family Vision Solutions and Specialty Contact Lens Center
Address: 2827 Waterbend Cove, Suite 100, Spring, TX, 77386, US
Telephone: 713-349-0224
Price range: $000 - $300

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Preferred Phone Number*

Please provide a telephone number, with area code, so we can contact you.
Do we have permission to leave voicemail?*
- Yes
- No
Do we have permission to send text messages and other communications?*
- Yes
- No
Daytime Phone
Cell Phone
Did one of our patients refer you to us?
- Yes
- No
Referred by
May we send a thank you note?
- Yes
- No
People with whom we can share your Protected Health Information (PHI)
Emergency Contact Name*
Emergency Contact Phone Number*

Please provide a telephone number with area code.
Someone authorized to make appointments and order or pick up glasses/contacts
Name
Relationship
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity*
Marital Status
Marital Status - Other

Please provide your marital status.
Employment Status
Employment Status - Other

Please provide your employment status.
Employer
Occupation
How were you referred to our office?
Referral Status - Other

Please let us know how you were referred to our office.
Communication Preference
Health History
Please check off any current conditions you suffer from
- I stopped wearing glasses
- I stopped wearing contact lenses
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
- Glaucoma
- Cataracts
- Macular Degeneration
- Retinal Detachment
- Keratoconus
- Heart Disease
- Diabetes
- Cancer
- Arthiritis
- Lupus
- Thyroid
- Kidney
- Nerves
- Asthma
- Anemia
- Hypertension
- Other
You chose "Other." Please specify:
I stopped wearing glasses because:
I stopped wearing contact lenses because:
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:

Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
What is your primary care physician's phone number?
What is your pharmacy's name?
What is your pharmacy's phone number?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had, besides those listed above
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Hidden
Please list all prescription and over-the-counter medications you take and for what conditions
For every medication, please include medication, strength, and dosage.
You can also bring your medication list to your appointment as well.
Please list all prescription and over-the-counter medications you take and for what conditions
Medication Strength Dosage

For every medication, please include medication, strength, and dosage.
You can also bring your medication list to your appointment as well.
Please list all drug allergies you have
Please check off any current conditions you suffer from
- Chronic fever, unexpected weight loss/gain, fatigue
- Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
- Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
- Respiratory problems (eg. Shortness of breath, wheezing, coughing)
- Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
- Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
- Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
- Skin problems (eg. Rashes, excessive dryness, growths or lumps)
- Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
- Psychiatric problems (eg. Depression, anxiety)
- Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
- Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
- Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Authorization for E-Mail Communication (Please note that this does not include Protected Health Information.)
Email Address

I hereby acknowledge that e-mail between Family Vision Solutions and me is not encrypted and therefore not guaranteed to be private. I grant permission for Family Vision Solutions to send newsletters, appointment reminders and appointment confirmations. I will notify Family Vision Solutions of any changes to my E-Mail listed here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Phone
This field is for validation purposes and should be left unchanged.

Patient Registration Form

Patient Information

People with whom we can share your Protected Health Information (PHI)

Someone authorized to make appointments and order or pick up glasses/contacts

Personal Information

Health History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Authorization for E-Mail Communication (Please note that this does not include Protected Health Information.)

Privacy Policy

Family Vision Solutions

Orthokeratology

Daily Disposable Contact Lenses

Medication	Strength	Dosage