Patient Registration Form

Name: Texas State Optical
Address: 724 Beechnut Street, Houston, TX, 77096, US
Telephone: 713-666-2277
Price range: $000 - $300

Thank you for choosing TSO for your vision care.

PATIENT INFORMATION:
Legal Name
Date
Address
Street Address Address Line 2 City State ZIP Code
Phone:
Home
Cell
Work
Email
SS#
Sex
- Male
- Female
Age
Birth Date
Height
Ft.
In.
Weight
Lbs.
Marital Status:
- Married
- Widowed
- Single
- Separated
- Divorced
- Minor
Occupation:
Employer/School
Employer/School Address:
Employer Phone:
Spouse's Legal Name
Spouse's Birth Date
Spouse's Employer
Preferred Communications:
- Email
- Phone
Best time to reach you
Preferred Language
- English
- Spanish
Race:
- Asian
- Black/African American
- White
- Native Alaskan/Native Hawaiian/Other Pacific Island Native
Ethnicity:
- Hispanic/Latino
- Not Hispanic/Latino
Emergency Contact:
Name
Relationship
Phone:
Home
Cell
Work
VISION INSURANCE
Ins. Company
Ins. ID
Group #
Member's Legal Name
Birth Date
Member's SS#
Relationship to Patient
MEDICAL INSURANCE
Ins. Company
Ins. ID
Group #
Member's Legal Name
Birth Date
Member's SS#
Relationship to Patient
I certify that I, and/or my dependent(s), have insurance coverage with
and assign directly to Dr.
Signature of Patient, Parent, Guardian or Personal Representative:
Relationship to patient:
Date:
PRIMARY CARE PHYSICIAN/REFERRING PHYSICIAN:
Name
Phone
Address
Fax
HEALTH HISTORY:
Please check all health issues you and/or any blood relatives have had.
YOU BLOOD RELATIVE
Aids/HIV
Anemia
Arthritis
Asthma
Attention Disorder
Autism
Blood Disorder
Cancer
Crohn's Disease
Diabetes
Epilepsy
Genitourinary Disorder
Headaches
Heart Disease
High Cholesterol
Hypertension

PATIENT INFORMATION: