Request an Appointment

Please fill out the form below and press "Submit". We will contact as soon as possible. Most appointments are confirmed within 24 hours. Items in bold are required.

Office Hours:
Monday - Friday: 9:00am - 6:00pm
Saturday: 9:00am - 4:00pm

Patient Information
First Name:	Last Name:
Address:	Have we seen you before? Yes No
City:	State:	Zip Code:
Social Security Number:	Date of Birth: MM DD YYYY
E-Mail:	Home Phone:
Work Phone:	Mobile Phone:
How did you find us? Please SelectReferal from Family or FriendPrint AdvertismentWorld Wide Web	Whom may we thank for refering us?
Appointment Information
Doctor: No PreferenceDr Lena ChuDr Robert ChuDr Katherine Mor	Location: Please SelectFort WorthSouthlake
Prefered day of the appt: Please SelectMondayTuesdayWendsdayThursdayFridaySaturday	Prefered Time: AM PM
Reason for Visit: Please SelectComprehensive Eye ExamEmergency Office VisitContact Lens CheckDry Eye Treatment/ Follow-upGlaucoma Treatment/ Follow-upOcular Disease Treatment/Follow-upOrthokeratology EvaluationLaser Vision Correction EvaluationOther	If "Other," please specify:
Please tell us about your eyes:
Insurance Information
Most insurance plans accepted.
Vision Benefits:	Medical Insurance (the insurance you use w/ your family doctor):
Not ApplicableVision Service Plan (VSP)United HealthcareMedicareSuperior Vision Plan (SVP)Davis VisionAetnaSpecteraBlue Cross Blue ShieldEyemedCignaCole Managed Vision CareOther	Not ApplicableMedicareUnited HealthcareBlue Cross Blue ShieldAetnaCignaGreat WestHealthmaketUnicarePacificarePHCSOther
If "Other," please specify:	If "Other," please specify:
Name of Primary Insured:	Group ID #:
Is the deductible met? Yes No