Patient Registration Form Welcome to Texas State Optical Thank you for choosing TSO for your vision care. PATIENT INFORMATION:Legal Name Date Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Home Cell Work Email SS# Sex Male Female Age Birth Date HeightFt. In.In. WeightLbs. 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 INSURANCEIns. Company Ins. ID Group # Member's Legal Name Birth Date Member's SS# Relationship to Patient MEDICAL INSURANCEIns. 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.YOUBLOOD RELATIVEAids/HIVAnemiaArthritisAsthmaAttention DisorderAutismBlood DisorderCancerCrohn's DiseaseDiabetesEpilepsyGenitourinary DisorderHeadachesHeart DiseaseHigh CholesterolHypertensionYOUBLOOD RELATIVEHepatitis/Liver DisorderKidney Disease/StonesLung DiseaseLupusMenopauseMigraine HeadachesMood DisorderMultiple SclerosisParkinson's DiseaseShinglesSkin DisorderStrokeThyroid DisorderTuberculosisOther EYE HEALTH HISTORY:YOUBLOOD RELATIVEGlaucomaMacular DegenerationDry EyesLazy EyePoor Night VisionFloaters/Flashes/SpotsYOUBLOOD RELATIVEPoor Color VisionRetinal DiseaseRetinal DetachmentCataractsEye InjuryHalos/GlareDo you smoke? Are you pregnant? Do you drink alcohol? Amount MEDICATIONS:List all medications you are currently taking, including eye drops.List any allergies to medications and/or other substances.Pharmacy Phone