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OD Network - Doctors Portal  
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  Patient Portal - Registration  
 


Before you can take advantage of our interactive features, you must first create an account.

You will be asked to create a User ID and password, as well as provide some information to validate who you are. We do this for your security and protection. The information you provide is encrypted and stored securely.

Please complete all of the information on the form so we can process your
prescription renewal requests without any hangups!

Becoming an online patient at our Virtual Office does not establish a doctor/patient relationship.

Already have an account? Click here to login now.

  
 

New Patient Account Form:

First Name:
 		Creat a Username:
Last Name:
 		Create Password (min 6 characters):
  Confirm Password:
Address:
 		 
 
City:
 		Home Phone:
State:
 		Work Phone:
Zip Code:
 		Cell Phone:
   

Gender:

Email Address:
Date of Birth:
 		Social Security Number:
   

Do you have insurance?

 
Primary Healthcare Provider:
 		Preferred Pharmacy:
Secondary Healthcare Provider:
 		Pharmacy Phone Number:
   
Eye Center of Texas Doctor:
 		Family Doctor:
  Family Doctor's Phone:
   
Additional Information We Should Know (250 Characters):
 

 
 
   
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