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Patient Registration Form

  • Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide your email address.
  • Date Format: MM slash DD slash YYYY
  • Medical History

  • Include Name of Medication, Dosage, Frequency Taken
  • Family History

    Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
  • Social History

    This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
  • REVIEW OF SYSTEMS

    Do you currently or have you ever had any problems in the following areas?
  • Constitutional

  • Neurological

  • Eyes

  • Endocrine

  • Ears, Nose, Mouth, Throat

  • Respiratory

  • Vascular/Cardiovascular

  • Gastrointestinal

  • Genitourinary

  • Bones/Joints/Muscles

  • Lymphatic/Hematologic

  • Allergic/Immunologic

  • Psychiatric

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

Call for an Appointment, We are open!

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

We kindly ask that you hold off on scheduling your appointment if…

  • You have traveled by plane in the last 3 weeks.
  • You have traveled out of the state or country in the last 3 weeks.
  • You are currently feeling ill or are having symptoms such as cough, fever, sore throat, ect.

Please call us in advance with any questions.

If you are a contact lens wearer with less than a 3 month supply, we encourage you to call in and place your orders to help avoid any possible future delays. Free shipping to your home address will be given with a 2 box purchase minimum.

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