We welcome new patients and accept most major forms of insurance.

Mon, Wed, Thu 7:30 AM–5 PM Tue 8:30 AM–5 PM Fri 7:30 AM–1 PM

York Eye Associates
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Patient Registration Form

Book an Appointment (opens in a new tab)Call 940-612-2020
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HEALTH HISTORY

Constitution:
Cardiovascular:
Ears, nose, mouth, & throat:
Musculoskeletal:
Gastrointestinal:
Genitourinary:
Psychiatric:
Respiratory:
Integumentary:
Neurological:
Endocrine:
Hematologic/Lymphatic:
Allergic disorders, Autoimmune Disorders, Drug Hypersensitivity, Food Allergy
Immunologic:

Past/Present/Family Ocular History: (Check All That Apply)

Glaucoma:
Cataracts:
Macular Degeneration:
Eye Injury:
Retinal Disease:
Blindness:
Strabismus:
Amblyopia:
Diabetes:
Dry Eye:
Eye Surgery:
Refractive:
Cancer:
Heart Disease:

Social History: (Check All That Apply)

Tobacco Use:
Illegal Drug Use:
Alcohol Use:
Do you work on a computer?

FOR WOMEN:

Are you pregnant?
Are you nursing?

Medications:

(Please list ALL prescription & over-the –counter medications you currently take)
Do you have any allergies to medications?

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Visit Us

York Eye Associates, P.C.

2020 West Hwy 82, Gainesville, TX 76240

Located a mile West of the I-35, US-82 intersection, on the left hand side after the Hospital

Book an Appointment (opens in a new tab)Call 940-612-2020
Monday7:30 AM - 5:00 PM
Tuesday8:30 AM - 5:00 PM
Wednesday7:30 AM - 5:00 PM
Thursday7:30 AM - 5:00 PM
Friday7:30 AM - 1:00 PM
SaturdayClosed
SundayClosed

Closed most holidays.