patient  information  form

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We ask that you fill out the entire Patient Information form. It saves time when checking in for your appointment. Thank you.

    patient  information  form

    medical insurance information
    (Sponsor's or self)

    Medical Insurance Information is collected in case of a medical emergency or should you choose to use it instead of vision insurance.

    Health history/review of systems

    ​EYES: Tell us about your eyes. What is your reason for this visit? Ex., glasses/contacts, loss of vision?
    Eye History
    Family History
    Health History
    Review of Systems
    ​PLEASE READ CAREFULLY:
    El Paso Optical Center = EPOC   
     
    I understand that me (or my dependent’s) medical records are confidential but may be reviewed by entities listed in the HIPAA Privacy form. I can remove this consent by written request to El Paso Optical Center. I assign EPOC all insurance benefits for services rendered.  I understand that I am financially responsible for ALL charges and balances left by my insurance.  In the event that my insurance does not compensate EPOC for services within 90 days, all balances will become my responsibility to pay. I will also be responsible for all attorney and collection agency fees.  
     
    I agree that I have read the above and fully understand and acknowledge the terms and conditions stated.
    Notice of Privacy

downloadable patient  information  forms

To save time, please download and complete the Patient forms before your appointment. We look forward to serving you!

El Paso OptICAL cENTER

4724 Montana Ave
​El Paso, TX 79903

(915) 566-8693
E-mail: appointment@ekery.com
Website: www.ekery.com

Mon - Thur - 8:00 am - 5:30 pm
LUNCH 12:00 PM - 1:00 PM​
Fri - 9:00 am - 1:00 pm

​Notice of Privacy Practices
Website by Eyefinity