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Online Forms

  • Medical History and Insurance

  • 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

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide your email address.
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  • Medical History

  • Include Name of Medication, Dosage, Frequency Taken
  • Family History

    Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
  • Social History

    This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.

    Do you currently or have you ever had any problems in the following areas?
  • Constitutional

  • Neurological

  • Eyes

  • Endocrine

  • Ears, Nose, Mouth, Throat

  • Respiratory

  • Vascular/Cardiovascular

  • Gastrointestinal

  • Genitourinary

  • Bones/Joints/Muscles

  • Lymphatic/Hematologic

  • Allergic/Immunologic

  • Psychiatric

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  • Insurance

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  • HIPAA Acknowledgment

  • Advanced Vision Care of North Arlington,
    PA 827 E. Lamar Blvd. Arlington, TX 76011

  • The law requires that Advanced Vision Care make every effort to inform you of your rights related to your personal health information. by my signing below. I acknowledge that:


  • MM slash DD slash YYYY
  • OPTOMAP Agreement

  • Advanced VisionCare offers a state-of-the-art digital scanning technology that allows us to see the inside of your eye without the use of dilation drops. The OPTOMAP allows us to evaluate your retina for problems such as macular degeneration, retinal holes, retinal detachments, hypertension and diabetic retinopathy. The scanning system is completely safe for kids and adults and allows you the opportunity to see the inside of your eye just as the doctor sees it.

    1. Blurred vision for 4-6 hours
    2. Light sensitivity for 4-6 hours
    3. Longer office visit to wait for drops to take effect
    4. No permanent record of your retina
    5. Only the doctor can see the retina
    1. No blurred vision
    2. No light sensitivity
    3. Map takes less that 2 minutes to process
    4. Permanent digital image that can be reviewed/compared each year
    5. You can see your retina

    Our doctors recommend that all patients have a thorough examination of their retina every year. Without the OPTOMAP or dilated examination, the doctor cannot fully assess the health of your eye. There is an additional fee of $32.00 for the OPTOMAP. In most cases, the procedure is not covered by insurance. Dilation may still be required in rare instances.

  • Permission to File Form

  • Permission for Filing Insurance

  • Your signature below gives Advanced VisionCare of North Arlington the permission to file an insurance claim on your behalf.
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  • Patients with Vision and/or Medical Insurance

  • In the event that your insurance states that you are not eligible for coverage at the time of service, or determines that you are eligible for a reduced level of coverage, by signing this statement, you hereby agree to be financially responsible for any and all charges incurred by you that are not paid by your insurance provider.
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  • This field is for validation purposes and should be left unchanged.