Glaucoma Associates of Texas

Glaucoma Eye Doctor, Specialty Ophthalmologists

Dallas214-360-0000 • Plano972-612-9522 • Fort Worth817-923-2000
Rockwall469-769-1606 • Sherman214-360-0000
Southlake 214-360-0000

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  • Home
  • About Us
    • Michelle R. Butler, MD
    • Lauren S. Dhar, MD
    • Matthew E. Emanuel, MD
    • Ronald L. Fellman, MD
    • David G. Godfrey, MD
    • Davinder S. Grover, MD MPH
    • Helen L. Kornmann, MD, PhD
    • Oluwatosin U. Smith, MD
  • Our Foundation
  • Gallery
  • Review Us
    • Testimonials
    • Patient Survey
  • Patient Information
    • Patient Forms
    • Your First Office Visit
    • Insurance
    • Office Policies
    • Preoperative Instructions
    • Postoperative Instructions
    • How to Use Eye Drops
    • Glaucoma Sitemap
  • Patient Portal
  • Contact us
    • Dallas Office
    • Fort Worth Office
    • Plano Office
    • Rockwall Office
    • Sherman Office
    • Southlake Office
  • Glaucoma
    • What is Glaucoma?
    • Types of Glaucoma
    • Childhood (Congenital) Glaucoma
    • Exercise and Glaucoma
    • Living with and Managing Glaucoma
    • Light Sensitivity and Glare with Glaucoma
    • Low Vision Due to Glaucoma
    • Nutrition, Lifestyle, and Glaucoma
    • Glaucoma FAQs & Definitions
  • Diagnosis & Testing
    • Diagnosis and Testing
    • Nerve Fiber Analysis
    • Gonioscopy
    • Visual Field Test
  • Glaucoma Treatments
    • Medical Treatment
      • Glaucoma Medications
      • How to Use Eye Drops
      • Compliance with Glaucoma Treatment
    • Laser Treatment
      • Types of Glaucoma Lasers
      • Micropulse Laser
      • Laser Iridotomy
      • Selective Laser Trabeculoplasty
      • Diode Cyclophotocoagulation (CPC)
  • Glaucoma Surgery
    • Types of Glaucoma Surgery
    • Canaloplasty Glaucoma Surgery
    • Endocyclophotocoagulation (ECP)
    • GATT Procedure
    • Glaucoma Drainage Implant Surgery
    • Glaucoma Filtration Surgery (Trabeculectomy)
    • Hydrus® Microstent
    • iStent® Trabecular Micro-bypass
    • Trabectome® Minimally-invasive Glaucoma Surgery
  • Cataracts and Glaucoma
    • Cataract Surgery
    • Cataract Surgery and Glaucoma
  • Research

New Patient Forms

Please download, print and complete the New Patient Forms prior to coming to our office. Faxing or carrying your patient forms with you to your appointment will, minimize your time spent in our waiting room. Please read our Office Protocol Acknowledgment page

Print these pages New Patient Forms 2015 PDF (53 kb)

Glaucoma Associates of Texas Patient Information Sheet

Patient’s Name

Nickname

Referring Physician

Address

City/State

Zip

Phone No.

(          )

Phone No. (Day) (          )

Sex (circle one)

 

Male          Female

Birth Date

S.S. #

Patient’s Employer

Occupation

Employer’s Address

Zip

Phone No.

(         )

Marital Status (circle one)

 

Single       Married        Widowed       Divorced

Age

Spouse’s Name

Spouse’s Employer

Notify in case of emergency

Address (street, city, state)

Phone No.

(         )

Notify in case of emergency (Not in household)

Address (street, city, state)

Phone No.

(         )

Dou have Medicare? (circle one)

 

Yes        No

Medicare Number

Do you have Medicaid? (circle one)

 

Yes        No

Medicaid Number

Do you have Texas Commission for the Blind? (circle one)

 

Yes              No

Counselor Name & City

Do you have Champus? (circle one)

 

Yes          No

If so, name of insured

Policy No.

S.S. #

Status (circle one) Active                Retired

Deceased

Do you have HMO or PPO? (circle one)

 

Yes          No

If so, name of company

Is pre-approval required? (circle one)

Yes          No

Address (street, city, state)

Zip

Contact Person

Phone No.

(         )

Name of Insurance Company (Private)

Policy No.

Is pre-approval required? (circle one)

Yes    No

Name if insured

Date of Birth of Insured

S.S. #

Patient’s relationship to insured

Address (street, city state, zip)

Name of Insurance Company (secondary)

Person to contact

Pre-approval required? (circle one)

 

Yes                No

Name of insured

Patient’s relationship to insured

                                         

 

 

Address (street, city, state, zip)

Is this a Worker’s Compensation Claim? (circle one)

Yes         No

Date of Injury

Contact person

Phone No.

(         )

I hereby authorize the Physician’s at GLAUCOMA ASSOCIATES OF TEXAS to perform such treatments to me as may be prescribed by any attending physician during any and all of my visits to GLAUCOMA ASSOCIATES OF TEXAS.

I understand that I am financially responsible for ALL charges arising from services rendered to me by GLAUCOMA ASSOCIATES OF TEXAS.

Patient’s Signature:                                                                                  

Date:                                        

 

I AUTHORIZE GLAUCOMA ASSOCIATES OF TEXAS TO FILE ON ANY AND ALL INSURANCE FOR ANY CHARGES THAT I INCUR. I REQUEST THAT ALL PAYMENTS FROM ANY OF THESE INSURANCES TO BE MAILED DIRECTLY TO GLAUCOMA ASSOCIATES OF TEXAS. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND IT’S AGENTS, OR INSURANCE COMPANY, ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.

 

Patient’s Signature:                                                                                  

Date:                                        

 

IT IS THE POLICY OF OUR OFFICE NOT TO TREAT MINORS WITHOUT THE CONSENT OF A PARENT OR LEGAL GUARDIAN. IF A WRITTEN ONE CANNOT BE OBTAINED, A PHONE CONSENT WILL BE REQUIRED.

Patient’s Signature:                                                                                 

Date:                                        

WELCOME TO THE GLAUCOMA ASSOCIATES OF TEXAS                                                                     1

Name:

Date:

Date of birth:

Address:

Telephone #:

Referring physician:

Telephone #:

Address:

Primary care physician:

Telephone #:

Address:

MEDICAL, FAMILY & SOCIAL HISTORY:  Please check the following as they apply to yourself (S) or to family members (F):

S

F

 

S

F

 

S

F

 

 

 

anemia

 

 

emphysema

 

 

 

 

 

arthritis

 

 

gout

 

 

kidney disease

 

 

asthma

 

 

heart attack

 

 

stroke

 

 

cancer

 

 

hepatitis

 

 

thyroid disease

 

 

diabetes

 

 

high blood pressure

 

 

vascular disease

Cause of death of parents, siblings and children:                                                                                  

Please circle "yes" or "no". Explain any "yes" answers.

Are you using non- prescription drugs?

no

yes,                                                                                                

Do you use street drugs?

no

yes,

Do you drink alcohol

no

yes, how much?

Do you smoke?

no

yes, how much?

Have you ever been exposed to the AIDS virus?

no

yes,                                                                                                

Have you ever had a sexually transmitted disease?

no

yes,                                                                                                

Do you get allergy shots?

no

yes,

Marital status:      single,      married,         widowed,     divorced,           other

Work status:             Current occupation:                                Previous occupation: Any known toxic exposure?  no / yes

Living arrangements:       home,         apartment,            nursing home,       other

Live alone?   yes / no                                  Status:        independent   /       need assistance

Education level:       high school,       college,       post-graduate degree,       other

Driving:

Do you drive in the day?        yes / no                                 with difficulty?        yes / no

Do you drive at night?            yes / no                                 with difficulty?        yes / no

       

WELCOME TO THE GLAUCOMA ASSOCIATES OF TEXAS                                                                       2

Name:                                                                               

Date:                                             

SKIN: itching, rash, infection, ulcer, tumors (growths), other

Explain:

none

LYMPH NODES: swelling, tenderness, other.

Explain:

none

BONES, JOINTS, MUSCLES:  muscle pain/cramps, joint pain/swelling, other.

Explain:

none

ENDOCRINE:  fatigue, confusion, fainting, nervousness, hot/cold intolerance, hair loss, excessive hair growth, other

Explain:

none

ALLERGY/IMMUNOLOGY:  recurrent infections, hayfever, hives, food allergy, drug sensitivity/allergy, other.

Explain:

none

HEAD: headaches, dizziness, vertigo, other.

Explain:

none

EARS: hearing loss, ringing, infections, other.

NOSE:  bleeding, loss of smell, congestion, other.

THROAT: dry mouth, loss of taste, difficulty swallowing, hoarseness, other. Explain:

none none none

NECK: pain swelling stiffness, other.

Explain:

none

BREASTS:  tenderness, swelling, lumps, discharge, other.

Explain:

none

BLOOD:  fever/chills, easy bruisability, prolonged bleeding, skin hemorrhages significant blood loss, other.

Explain:

none

RESPIRATORY: wheezing cough (productive/blood), difficulty breathing, other.

Explain:

none

CARDIOVASCULAR (HEART/BLOOD VESSELS):  chest pain, cold hands/feet, swelling of extremities, shortness of breath, exercise intolerance, other.

Explain:

none

GASTROINTESTINAL (stomach/intestines):  nausea, vomiting, change in bowel habits, constipation, diarrhea, bleeding, pain/cramps, other.

Explain:

none

GENITOURINARY (genitals/kidneys/bladder):  frequency, burning, hesitancy, pain or bleeding on urination, stones, infections, incontinence, impotence, other.

Explain:

none

NERVOUS SYSTEM:  weakness in arms/legs, numbness/tingling, loss of

consciousness, falls, difficulty walking, seizures, tremors, neuralgia, other. Explain:

none

PSYCHIATRIC:  disorientation, mood swings, anxiety, depression, hallucinations, other.

Explain:

none

 

 

REVIEW OF SYSTEMS:  If you are currently having any problems in the following areas, circle and explain (if necessary).

 

This form completed by:                                                                   

 

CONSENT

TO THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS, AND AS OTHERWISE ALLOWED BY LAW

 

Glaucoma Associates of Texas (hereinafter referred to as “Glaucoma Associates”) will maintain a record of the care and services you receive at Glaucoma Associates. This consent only covers your protected health information created while you are a patient of Glaucoma Associates. Your protected health information pertains to your diagnosis and/or treatment at Glaucoma Associates, including but not limited to information concerning mental illness (except for psychotherapy notes), use of alcohol or drugs or communicable diseases such as Human Immunodeficiency Virus (“HIV”), and Acquired Immune Deficiency Syndrome (“AIDS”), laboratory test results, medical history, treatment progress or any other such related information.

By signing this form, you consent to Glaucoma Associates’ use and/or disclosure of protected health information about you for treatment, payment, health care operations and as otherwise allowed by law. Our Notice of Protected Health Information Practices provides information about how Glaucoma Associates and its physicians may use and/or disclose protected health information about you for treatment, payment, health care operations and as otherwise allowed by law. By signing this form, you also acknowledge that you have received a copy of Glaucoma Associates’ Notice of Protected Health Information Practices and an opportunity to review it before signing this consent.

 

Signature of Patient or Legal Representative                                        Witness

Date

 

Copyright © 2003 Burford & Ryburn, L.L.P.

 

GLAUCOMA ASSOCIATES OF TEXAS

RONALD L. FELLMAN, M.D. DAVID G. GODFREY, M.D. OLUWATOSIN U. SMITH, M.D.

DAVINDER S. GROVER, M.D., M.P.H. MICHELLE R. BUTLER, M.D. Matthew Emanuel, MD

Patient Authorization To Release Protected Health Information

I authorize Glaucoma Associates of Texas to release protected health information to the individual (s) listed below for the purpose of assisting with my care and/or payment.

Name

 

Relation

 

Phone Number

Name

 

Relation

 

Phone Number

Name

 

Relation

 

Phone Number

 

Description of the information to be used or disclosed (check all that apply):

  • Patient’s demographic information
  • Patient’s medical information
  • Patient’s billing information
  • Appointment Status

I understand that this authorization will be in effect during the time period I am a patient at Glaucoma Associates of Texas.

I further understand that this authorization is voluntary and that my health care and the payment of my health care will not be affected if I do not sign this form.

I further understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations.

I further understand that I may revoke this authorization at any time by notifying Glaucoma Associates of Texas in writing at 10740 N. Central Expressway, Suite 300, Dallas, TX 75231. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.                                                           

Signature of Patient or Patient’s Representative                                Date

 

Printed name of Patient’s or Patient’s Representative

 

Relationship to Patient or Legal Authority

10740 N. CENTRAL EXPRESSWAY Ÿ SUITE 300 Ÿ DALLAS, TX 75231 Ÿ (214) 360-0000 Ÿ (800) 683-0386 Ÿ FAX (214)360-0083

417 W. MAGNOLIA AVENUE Ÿ FORT WORTH, TX 76104 Ÿ (817) 923-2000 Ÿ FAX (817) 923-6639

WWW.GLAUCOMAASSOCIATES.COM

Sherman Office Now Open

Glaucoma Associates of Texas (GAT) would like to welcome you to our new GAT Sherman Office located in Sherman, Texas. We are excited to announce that this is our fifth office in the Dallas-Fort Worth metropolitan area. Our goal is to bring glaucoma specialists closer to your area.

Our Mission

Glaucoma Associates of Texas, Dallas, Plano, Fort Worth and Rockwall

The doctors at Glaucoma Associates of Texas (GAT) are ophthalmologists specializing in the medical, laser, and surgical treatment of glaucoma and cataracts. Each of our physicians has completed a clinical glaucoma fellowship, gaining extensive … Glaucoma Specialists

Our Video Gallery

GATT (Gonioscopy Assisted Transluminal Trabeculectomy)

Welcome to the Glaucoma Photo Gallery and Video Gallery for Glaucoma Associates of Texas! Glaucoma Video Gallery In our first video, Dr. Davinder Grover is interviewed by Cheryl Guttman Krader of Ophthalmology Times. The article about GATT … Video Gallery

Our Charity – Cure Glaucoma

cure glaucoma fund

Glaucoma Associates of Texas   Cure Glaucoma, a charitable foundation, was established in 2014 by ophthalmologists at Glaucoma Associates of … Cure Glaucoma

Archives

Latest GAT News

What’s the Right Surgery for You?

December 10, 2017 By Matthew Emanuel, MD

Click Here to watch Dr. Davinder Grover discuss how glaucoma-trained … [Read More...]

Make the Most of Your Visit

December 2, 2017 By Matthew Emanuel, MD

Click Here to see Dr. Tosin Smith's recent interview on 7 Ways to Make the … [Read More...]

Living With Glaucoma

  • Living with and Managing Glaucoma
  • Low Vision Due to Glaucoma
  • Light Sensitivity and Glare with Glaucoma
  • Nutrition, Lifestyle, and Glaucoma
  • Exercise and Glaucoma
  • Cure Glaucoma Charity

GAT Dallas Office

GAT Plano Office

GAT Fort Worth Office

GAT Rockwall Office

GAT Sherman Office

GAT Southlake Office

5 Office Locations

Dallas Office 214-360-0000
10740 N Central Expressway, Suite 300
Dallas, Texas 75231

Plano Office 972-612-9522
6000 W.Spring Creek Pkwy, Suite 110
Plano, TX 75024

Fort Worth Office 817-923-2000
417 W Magnolia Avenue
Fort Worth, Texas 76104

Rockwall Office 469-769-1606
810 Rockwall Pkwy, #1010
Rockwall, Texas 75032

Sherman Office 214-360-0000
715 E. Taylor Street
Taylor Plaza, Suite 100
Sherman, TX 75090

Southlake Office 214-360-0000
305 Morrison Park Drive
Southlake, Texas 76092

Stay In Touch

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In An Emergency Dial 911

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