OD Referral Forms and Maps

Patient Care Referral Form
Bellaire Map
Pasadena Map
Clear Lake Map
Sugar Land Map
Katy Map
Woodlands Map
All Locations

Necessary Forms for LASIK Patients

Informed Consent for Lasik Patients (178 KB)
LASIK – Post Op Drops Form
LASIK Post Op Form
LASIK Post-Op Instructions for Patients (44 KB)
LASIK Pre-Op Report (30.67 KB)
Lifetime Limited Warranty (56.5 KB)

Refractive Surgery Forms (LASIK)

LASIK Mono Vision Policies
Pregnancy Nursing Disclosure
The WaveScan WavePrint System
LASIK Pre-Op Patient Instructions
Near Vision
Driver’s License Changes After LASIK
Visian ICL vs Other Procedures

Refractive Surgery Forms (PRK)

PRK Post-Op-Drops

New Patient Forms

HIPAA – English (38.5 KB)
HIPAA – Spanish
Lifestyle Vision Questionnaire – English (61.48 KB)
Lifestyle Vision Questionnaire – Spanish
Medical History Form (46.66 KB)
Medical History Spanish (16.42 KB)
Visual Assessment Questionnaire – Right
Visual Assessment Questionnaire – Left
Visual Assessment Questionnaire Spanish
Welcome Letter (16.46 KB)
Billing Policy

Disease of the Eyes – Patient Handouts

Adenoviral Eye Infection
Cataract, What Is It
Diabetic Patient and Eye Disease
Macular Degeneration Prevention Guide… Vitamins (1.19 MB)
Retina Holes, Tears and Retina Detachment (254.5 KB)
Trabeculectomy, What Is It
YAG Laser Capsulotomy
Yag Laser Peripheal Iridotomy or YAG


Cataract 1 Day Post Op (201.5 KB)
Cataract 1 Week Post Op Forms (210 KB)
Cataract Post Op Check List for OD
Cataract Post-Op Instructions (266 KB)
Cataract PreOp Sx Instructions (286.5 KB)
Custom Intraocular Lens Lifetime Warranty (81.93 KB)
General Follow Up Exam Form for Patient’s Chart (45.5 KB)
Informed Consent for Cataract Patient (275 KB)
Generic vs Brand Cataract Drops (155 KB)
Before and After Cataract Instructions and Drops
After Cataract Drop Schedule
LenSx Laser Patient Education Brochure


Bleph – Disclosure and Informed Consent for Medical (216.5 KB)
Bleph Post Op Home Instructions (237 KB)
Lid Scrub Hygiene – English (269.5 KB)
Lid Scrub Hygiene – Spanish (250.5 KB)
Medical Necessity for Upper Bleph (37.5 KB)


Glaucoma Consultation Form (281 KB)
Glaucoma SLT Laser Information – Patient Handout (255 KB)
Informed Consent for SLT for Glaucoma – English (262.5 KB)
Informed Consent for SLT for Glaucoma – Spanish (284.5 KB)

Financing Options Available

Apply today to find a financing option that meets your needs.

Our Locations