Welcome to Prestonwood EyeCare

Prestonwood Eyecare

Online Patient Registration

Please fill out this form completely. By registering online, you reduce the amount of paperwork required when you arrive in our office for your appointment. All of your information is kept strictly confidential. Please read our Privacy Policy.

New Patient: Current Patient

Name:

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Date of Birth:

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Insurance Information
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Insured's Name:
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What is your current eye correction? No Prescription Glasses Soft Contact Lenses Rigid Contact Lenses

The Reason For Your Examination
Routine Eye Exam	Eye Injury	Cataract
Contact Lenses	Red Eyes	Itching
Tearing	Blurred Vision	Infection
Headache	Double Vision	Loss of Vision
Eye Pain	Glaucoma	Other
Laser Vision Correction
Date of last eye examination:

Your Medical History
Allergies	Asthma	Diabetes
Arthritis	Cancer	Heart Disease
Thyroid	Head Injury	High Blood Pressure
Other

Your Eye History
Cataract	Eye Injury	Glaucoma
Eye Surgery	Lazy Eye	Eye Infection
Vision Loss	Head Injury	Retinal Problems
Macular Degeneration	Floaters, Flashes	Other

Family Medical and Eye History
Cataracts	Glaucoma	Blindness
Diabetes	Heart Disease	Macular Degeneration
Retinal Problems	Other

List any Allergies that you have to Medication:

List Medication you are currently taking:

Please use this space to submit questions:

Dr. David C. Moiger, Therapeutic Optometrist
Location:	Prestonwood Creek / 5425 Beltline Road, Dallas Northeast corner of Beltline and Prestonwood Blvd.
Phone:	972-980-1774 / Fax: 972-980-0650
Hours:	Mon-Fri 9:30am - 6:00pm / Sat 9:30am - 4:00pm
E-mail: dallaseyes4u@aol.com
Hablamos Espanol!