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Patient Information
Patient is:
Is the Patient a UH employee or student?

Patient's Name
First Name: Last Name:
Primary Contact's First Name: Primary Contact's Last Name:
Patient's Age:
Patient's Date of Birth:
 (MM/DD/YYYY)

Mailling Address
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 Apt: 
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Email Address:
Insurance Information
  
Insurance Provider:

Please enter your Policy ID Number, Group Number and Name of the Policy Holder

Provider ID Number:
Group Number:
Policy Holder Name:
  
Appointment Type
(if this is an emergency, please call (713) 743-2010)
What type of appointment do you need?
Family Practice
Provides complete vision care for individuals 6 years of age and older. A complete assessment for both internal and external eye health is performed. Glaucoma, macular degeneration and cataracts are examples of some of the more common eye diseases that are detected.
 
Would you like to request a specific Doctor?
Cornea and Contact Lens Service
Provides comprehensive vision care and ensures contact lenses are comfortable and provide the clearest vision possible. Standard and custom-designed contact lenses are available.
 
Would you like to request a specific Doctor?
Cornea and Contact Lens Service
Provides comprehensive vision care and ensures contact lenses are comfortable and provide the clearest vision possible. Standard and custom-designed contact lenses are available.		 Family Practice
Provides complete vision care for individuals 6 years of age and older. A complete assessment for both internal and external eye health is performed. Glaucoma, macular degeneration and cataracts are examples of some of the more common eye diseases that are detected.
 
Would you like to request a specific Doctor?
Center for Sight Enhancement (Low Vision)
Low-vision rehabilitation is a specialized field targeting patients whose vision cannot be improved to normal levels with regular glasses, surgery or medication. Our team of professionals addresses functional vision loss such as: difficulty reading a newspaper, seeing street signs or any visual problem hindering daily living even after spectacle correction.
 
Would you like to request a specific Doctor?
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Our Office hours are between 8AM - 6PM Monday through Friday
  
Would you prefer a morning or afternoon appointment?
 

How did you hear about us:
  
Web Address or Name:   
  
  
Where did you hear about us?   
  
 
Once your request is recieved you will be contacted to schedule your appointment.