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Southlake | 817-310-3989

Ft. Worth - 7th St. | 817-348-9090

Ft. Worth - Hulen | 817-346-7077

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TELEMEDICINE

Telemedicine Appointments

We are offering telemedicine services via Apple Facetime for some appointment types (medical office visits that do not require special testing or refraction). You can either call our office for further details or complete the form below.

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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
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*

Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address

Please provide us your email address.
Date of Birth*
MM slash DD slash YYYY

Reason for Appointment
Share your chief complaint / Reason for Appointment
Medication History
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please list any surgeries you ever had.
Please check off any current conditions you suffer from
- Chronic fever, unexpected weight loss/gain, fatigue
- Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
- Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
- Respiratory problems (eg. Shortness of breath, wheezing, coughing)
- Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
- Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
- Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
- Skin problems (eg. Rashes, excessive dryness, growths or lumps)
- Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
- Psychiatric problems (eg. Depression, anxiety)
- Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
- Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
- Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Choice of Payment*
- Insurance
- Self Pay
Medical Insurance
Please bring all insurance cards with you to your appointment.
Do you have medical insurance?*
- Yes
- No
Insurance Company Name*
Insurance Company Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name*
First Last
Identification Number*
Group Number*
Insured's Date of Birth*
MM slash DD slash YYYY
Patient's Relation to Insured*
Vision Insurance
You can also enter any secondary insurance.
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name*
Insurance Company Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name*
First Last
Identification Number*
Group Number*
Insured's Date of Birth*
MM slash DD slash YYYY
Patient's Relation to Insured*

Choose Date & Time
Preferred Date*
MM slash DD slash YYYY
Preferred Time*
Comments
Health Information Protection*
- I have read and agree to the Privacy Policy
Telemedicine Consent Form*
- I have read and agree to the Telemedicine Consent Form
Email
This field is for validation purposes and should be left unchanged.

About Us
Doctors
Services
Patients
Locations

About Us
Doctors
Services
Patients
Locations

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EYEWORKS – West 7th - Located at 3017 W 7th St, Suite 100 & 210, Fort Worth, TX 76107. Phone: 817-348-9090 . https://www.eyeworksgroup.com

EYEWORKS – Southlake - Located at 3105 E Southlake Blvd, Southlake, TX 76092. Phone: 817-310-3989 . https://www.eyeworksgroup.com

EYEWORKS – Hulen - Located at 4631 S Hulen St, Fort Worth, TX 76132. Phone: 817-346-7077 . https://www.eyeworksgroup.com

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