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(713) 322-5520
We're located at 724 Meyerland Plaza

CARING FOR
THE EYES OF TEXAS

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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: