New Patient Form

The mission of EaDo Optics is to contribute to a lifetime of healthy vision, providing each patient with the highest quality vision care and consequent quality of life. Thank you for choosing us for your eye care needs!
Please notify us by call, text, or email if you need to reschedule or cancel!

Things to consider:
- Bring most recent prescriptions or current glasses/contact lens boxes
- Come in wearing contacts, if possible, for contact lens exams
- Have most recent exam records faxed to our office at 281-744-3066
- In certain situations, you may be informed to seek medical treatment for an eye condition before proceeding with a "routine" or "annual exam". Please bring all insurance cards.
Patient Name*
Birth Date*

MonthDayYear
If applicable, guardian completing form: NAME and RELATION
How did you first hear about us?*

Friend/FamilyInsurance/Vision PlanPass-byGoogleSocial MediaOther
Who can we thank with a $10 credit?
ELECTRONIC/DIGITAL CONSENT. Prescriptions and invoices are preferred via our patient portal to reduce paper waste.*

I consent to digital copies of prescriptions and invoices.I prefer paper copies of requested documents.

PRIVACY POLICY SUMMARY. In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct healthcare operations involving our office.*

I have read and/or obtained a copy of the Privacy Policy document below.I am having trouble loading the PDF but aware that it is available to view anytime at https://eadooptics.com/privacy-practices/ .
FINANCIAL DISCLAIMER. Please note that vision care plans will have copays associated with eye exams, contact lens services, and retinal imaging for ocular health screening.

Eligibility for medical insurance and/or routine vision benefits: We will attempt to verify your plan eligibility for services and/or materials before your appointment. Verification of eligibility and billing of insurances and vision benefits are done as a courtesy only and it’s not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility or benefits.
- All fees for professional services are non-refundable and payable at the time of service.
- If you have medical insurance or routine vision benefits, you authorize your plan carrier to directly pay EaDo Optics. You also authorize EaDo Optics to release any information required for payment to be made. If your plan carrier does not pay or partially pays, you understand you are responsible for payment in full or the remaining balances.
Signature for Financial Disclaimer*

Clear
Sign Here
MonthDayYear
Date