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  Make A VIP Appointment Online!  
 


You've read the information on our website, now it's time to take the next step!

Use the form below to request an appointment with
The Eye Center of Texas and enjoy a free, no obligation consultation with one of our top surgeons.

You'll discover which procedure is best for you, including all possible options, and get your questions answered with the personal professional attention you deserve.

 

 

Once you complete this form, click SEND and a friendly staff member will contact you to arrange the consultation at a time that is convenient for you.

Thank you for choosing The Eye Center of Texas for your vision needs!

 

 

Appointment Request Form:     (fields in red are required)
 
 

First Name:
I am Requesting an Appointment For:
Last Name:
Preferred Office Location:
Gender:
Preferred Date:
Preferred Time:
   
Address:
Preferred Contact Method:
 
City:
Home Phone:
State:
Work Phone:
Zip Code:
Cell Phone:
   
Date of Birth:
Email Address:
Social Security Number:
How Did You Hear About Us:
   
I am a:


Do you have insurance?

Current Optometrist:
Primary Healthcare Provider:
Eye Center of Texas Doctor:
Secondary Healthcare Provider:
   
Additional Information We Should Know:
 

 

 

   
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