Patient Registration

PDF documents can be downloaded by clicking on the links below

For new patients, please download, complete and bring the following form to your appointment. If you wish to register patient information online, please contact the office with your email address. You will receive an email with instructions on how to set password for the patient portal. The email link will expire in 72 hours or you can use “Forgot Password” link on the login page.

Patient Registration Form

Đơn Kê Khai Lý Lịch Bệnh Nhân

Información Del Paciente Formulario


      1. Financial Policy

      2. Privacy Notice

      3. Medical Record Policy

      4. Medical Record Release to Alliance Retina

      5. Medical Record Release from Alliance Retina to Provider

      6. Patient Registration Form

      7. Directions and Maps

      8. Patient Portal User Guide


We will verify the specific requirements in your insurance contract regarding deductibles, payments, copayments, and the terms regarding referral numbers, number of allowable visits to specialist, and in-office procedures. If your insurance requires you to pay a co-pay, then you must pay this co-pay at the time of your appointment. Your visit or treatment may be rescheduled if prior authorization from your primary care physician is required. Payment of unauthorized services is then your responsibility. Fees not covered by your insurance company due to unmet deductibles are due as you leave the office. If this should be the case, we offer payment plans to ensure your treatment does not go unfinished. If you have a question on whether we accept your insurance, please call our office at (817)617-7678.

Please email the office with your insurance information as soon as you scheduled your appointment. This allows us to verify your benefits and to file with your insurance claims correctly.