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Preferred Date
Preferred Time
09:00 AM
09:20 AM
09:40 AM
10:00 AM
10:20 AM
10:40 AM
11:00 AM
11:20 AM
11:40 AM
12:00 PM
02:00 PM
02:20 PM
02:40 PM
03:00 PM
03:20 PM
03:40 PM
04:00 PM
04:20 PM
04:40 PM
05:00 PM
Full Name
Date of Birth
Reason for Visit
New Patient Eye Exam
Returning Patient Eye Exam
Contact Lens Follow Up
Medical Eye Exam
Insurance
Aetna
Avesis
Blue Cross Blue Shield
Boon Chapman
Cigna
Community Eye Care
Davis Vision
Entrust
Evolve Benefits Options
EyeMed
Eyequest
Eyetopia
Group & Pension Administration
Health Comp
Humana
ITPEU Health & Welfare Plan
Medicaid
Medicare of Texas
Meritain Health
Molina Health Care of Texas
NVA
Spectra (OptumHealth Vision)
Superior Vision Services (DVP)
Tricare East
Tricare for Life
United Health Care
Unknown Carrier
Vision Care Plan
VSP
No Insurance
Insurance ID #
Phone
Email
Address
Send
Please Fill out and Print the following forms, prior to your appointment.
Contact Lens Agreement
Download
Insurance
Download
Notice of Privacy
Download
Patient Intake Form
Download
Reason for Visit
New Patient Eye Exam
Returning Patient Eye Exam
Contact Lens Follow Up
Insurance
Aetna
Avesis
Blue Cross Blue Shield
Boon Chapman
Cigna
Community Eye Care
Davis Vision
Entrust
Evolve Benefits Options
EyeMed
Eyequest
Eyetopia
Group & Pension Administration
Health Comp
Humana
ITPEU Health & Welfare Plan
Medicaid
Medicare of Texas
Meritain Health
Molina Health Care of Texas
NVA
Spectra (OptumHealth Vision)
Superior Vision Services (DVP)
Tricare East
Tricare for Life
United Health Care
Unknown Carrier
Vision Care Plan
VSP
No Insurance
Full Name
Date of Birth
Phone
Email
Address
Send
Please Fill out and Print the following forms, prior to your appointment.
Contact Lens Agreement
Download
Insurance
Download
Notice of Privacy
Download
Patient Intake Form
Download