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Request an Appointment
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Thank you for registering on-line for your Ophthalmology appointment. Please indicate how you wish to receive notification of your appointment:
e-mail
phone
• Denotes required information
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Patient
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• Patient Name
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| • Address |
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| • City |
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| • State |
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| • Zip Code |
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| Country |
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| • Daytime Phone Number |
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| • E-mail Address |
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| Date of Birth |
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| Gender |
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| Are you a new patient?
yes
no |
| If not, who is your treating physician? |
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Appointment Preference
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| Day of the Week |
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| Time of Day |
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| When |
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Primary Insurance
(Please bring your insurance card on the date of your appointment)
If your insurance information has changed since your last visit, or you are a new patient, please fill out the form below. |
| Insurance Company |
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| • Health Insurance Type |
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| • Insured's Name |
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| • Member ID Number |
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| • Employer Name & Group Number |
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| • Verification/ Customer Service Number |
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| • Treating Physician's Name |
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| • Physician's Phone Number |
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| If you are requesting an appointment for another person, please tell us how to contact you. |
| • Your Name |
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• E-mail Address
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| • Daytime Phone Number |
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Additional Information
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| Reason for Appointment/ Additional Comments: |
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Insurance Authorization and Assignment
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I hereby authorize my insurance company to pay Baylor Eye Consultants for services rendered to me or my family member. I also agree to pay for services on my account as services are provided. if, for any reason, I have a balance on my account, I agree to pay promptly upon receipt of a statement. I acknowledge and understand I am responsible for all charges for services rendered to me or any member of my family. I authorize release of any information to process my claim.
Click "Submit" to forward form to the Department of Ophthalmology. |
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| For general questions about appointment making, refer to our Frequently Asked Questions section. |
