© 2017 BY EDDIE.

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Midland, Texas / info@midlandvision.com / (432)694-2051

patient history form

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Do you wear glasses?
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Do you wear contact lenses?
Do you have any alergies to medications?
Do you suffer from headaches?
Do you suffer from seasonal allergies?
Are you taking any medication?
Are you pregnant?
Do you see flashes of light in your eyes?
Do you see floating objects in your eyes?
Do you suffer from emporary blackouts of your vision?
Do you suffer from:
Have your eyes ever suffered from:
Have you had previous eye surgery for?
Has anyone in your family suffered from?
Insurance Card
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DL or ID
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By pressing submit you agree everything on this form is correct or best to you Knowledge. All insurances must be presented at the time of service. Payment must be collected at time service is rendered. For insurance patients, please be aware that you are fully responsible for the services not covered by your insurance plan. I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. 

All checkbox fields must be checked to submit the form.  Please wait for 5 to 10 seconds for the form to submit. Once you get  "Thank You" you will know the form was submitting correctly.