TSO Keller Patient Registration Form

TSO Keller Patient Registration

Title

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone (or Cell if no home)*

Cell Phone

Work Phone

Email*

Personal Information

Sex

Male
Female

Date of Birth*

Social Security Number (Last four digits only!)

XXXX

Preferred Language*

Race*

Ethnicity*

Marital Status

Employment Status

Full-time
Part-time
Retired
Not Employed

Employer

Occupation

How were you referred to our office?

Other: Please Specify

Communication Preference

Eye History

Please check off any current conditions you suffer from

Do You Wear Glasses?*

Yes
No

Do You Wear Contact Lenses?*

Yes
No

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?*

Yes
No

Do you smoke?*

Yes
No

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Secondary Insurance

If you have coverage through another plan/organization, please fill in the details below.

Do you have secondary insurance?

Yes
No

Insurance Company Name

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

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