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Grand Prairie
972.264.7200

Forney
972.552.2020

Order Contacts

Did you know that you can order your contact lenses online and have them shipped to your door? Just click on the 20/20 Sight location where you had your eye exam to order your contact lenses.

Grand Prairie

Forney

Appointment Request

Fill out our short form to request an appointment that is convenient for you.

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Patient Registration
If you are a new patient, please submit this form before coming into the office.
Patient Information
Which location will you visit? *
Type of exam needed *
Last Name *
First Name *
Middle Initial
Address *
City *
State *
Zip Code *
Home Phone Number *
Daytime Phone Number
Cell Phone Number
Email Address *
Gender *
Age *
Birthdate * mm/dd/yyyy
Social Security Number For security purposes, we will call later to get this information
Marital Status *
Employer
Occupation
How did you hear about us? *
Whom may we thank for referring you?
Guarantor Name *
Guarantor Date of Birth * mm/dd/yyyy
Guarantor SSN For security purposes, we will call later to get this information
Relationship to patient *
Insurance Information
Insurance Company
ID or SSN For security purposes, we will call later to get this information
Group Number
Subscriber Name
Address
City
State
Zip Code
Home Phone Number
Email Address
Gender
Birthdate mm/dd/yyyy
Other Insurance
If the patient is covered by additional insurance, please fill out this section. Otherwise, you may skip to the next section.
Insurance Company
ID or SSN For security purposes, we will call later to get this information
Group Number
Subscriber Name
Address
City
State
Zip Code
Home Phone Number
Email Address
Gender
Birthdate mm/dd/yyyy
Eye Problems
Please indicate if you have experienced any of the following:
Blurry Vision - Near *
Blurry Vision - Distance *
Burning Eyes *
Cataracts *
Color Vision Poor *
Crossed or Turned Eyes *
Discharge from Eyes *
Dizzy Spells *
Double Vision *
Dryness *
Eye Infection *
Eye Injury *
Eye Strain *
Eye Pain *
Fainting Spells or Blackouts *
Floaters or Spots *
Flashes of Light *
Glaucoma *
Headaches *
Itchy Eyes *
Lazy Eye *
Light Sensitivity *
Loss of Vision *
Macular Degeneration *
Night Vision, poor *
Redness *
Twitching Eye *
Watery Eye *
Other
Patient History
Please indicate if you or a blood relative has experienced any of the following:
Yourself Family Members
Amblyopia (lazy eye) *
Blindness *
Keratoconus *
Glaucoma *
Macular Degeneration *
Strabismus (eye turn) *
Eye Surgery *
AIDS / HIV *
Allergies / Hay Fever *
Arthritis *
Asthma *
Bleeding *
Cancer *
Diabetes *
Drug Sensitivity *
Emphysema *
Epilepsy *
Heart Condition *
Hepatitis *
High Blood Pressure *
Kidney Disease *
Lupus *
Stroke *
Thyroid Conditions *
Tobacco Use *
Alcohol Use *
Women, Pregnant or Could Be?
Allergies List any allergies and/or allergies to medications
Medications List any medications you are currently taking, including eye drops
Acknowledgement & Submission
I request that payment of authorized Medicare benefits and if applicable, Medigap benefits, be made either to me or on my behalf to 20/20 Sight for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits for related services.
Check the box to indicate that you agree with the statement above *
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