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Patient Registration Form

Welcome to Texas State Optical

Thank you for choosing TSO for your vision care.
  • PATIENT INFORMATION:

  • Phone:
  • Ft.
  • In.
  • Lbs.

  • Emergency Contact:

  • Phone:
  • VISION INSURANCE

  • MEDICAL INSURANCE

  • I certify that I, and/or my dependent(s), have insurance coverage with


  • and assign directly to Dr.
  • PRIMARY CARE PHYSICIAN/REFERRING PHYSICIAN:

  • HEALTH HISTORY:

  • Please check all health issues you and/or any blood relatives have had.
  • YOUBLOOD 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
  • YOUBLOOD RELATIVE
    Hepatitis/Liver Disorder
    Kidney Disease/Stones
    Lung Disease
    Lupus
    Menopause
    Migraine Headaches
    Mood Disorder
    Multiple Sclerosis
    Parkinson's Disease
    Shingles
    Skin Disorder
    Stroke
    Thyroid Disorder
    Tuberculosis
  • EYE HEALTH HISTORY:

  • YOUBLOOD RELATIVE
    Glaucoma
    Macular Degeneration
    Dry Eyes
    Lazy Eye
    Poor Night Vision
    Floaters/Flashes/Spots
  • YOUBLOOD RELATIVE
    Poor Color Vision
    Retinal Disease
    Retinal Detachment
    Cataracts
    Eye Injury
    Halos/Glare
  • MEDICATIONS:

Call for an Appointment, We are open!

We are making special arrangements with the current public health concerns. When you call Texas State Optical Meyerland, we will space your appointment time to be mindful of social distancing and your personal comfort.

Texas State Optical Meyerland is here for your vision care. We are aware of your concerns and are taking extra precautionary action for your protection and safety. We carefully sanitize all surfaces, including equipment, frames and supplies, frame boards, desks, and keyboards.

When you schedule your eye exam appointment, you can have the extra confidence that you will be safe and comfortable at Texas State Optical.

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