Patient Registration Form Welcome to Texas State Optical Thank you for choosing TSO for your vision care. PATIENT INFORMATION:Legal NameDateAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:HomeCellWorkEmailSS#SexMaleFemaleAgeBirth DateHeightFt.In.WeightLbs.Marital Status:MarriedWidowedSingleSeparatedDivorcedMinorOccupation:Employer/SchoolEmployer/School Address:Employer Phone:Spouse's Legal NameSpouse's Birth DateSpouse's EmployerPreferred Communications:EmailPhoneBest time to reach youPreferred LanguageEnglishSpanishRace:AsianBlack/African AmericanWhiteNative Alaskan/Native Hawaiian/Other Pacific Island NativeEthnicity:Hispanic/LatinoNot Hispanic/LatinoEmergency Contact:NameRelationshipPhone:HomeCellWorkVISION INSURANCEIns. CompanyIns. IDGroup #Member's Legal NameBirth DateMember's SS#Relationship to PatientMEDICAL INSURANCEIns. CompanyIns. IDGroup #Member's Legal NameBirth DateMember's SS#Relationship to PatientI certify that I, and/or my dependent(s), have insurance coverage withand assign directly to Dr.Signature of Patient, Parent, Guardian or Personal Representative:Relationship to patient:Date:PRIMARY CARE PHYSICIAN/REFERRING PHYSICIAN:NamePhoneAddressFaxHEALTH 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 DisorderTuberculosisOtherEYE 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?AmountMEDICATIONS:List all medications you are currently taking, including eye drops.List any allergies to medications and/or other substances.PharmacyPhone
