Texas State Optical McKinney – New Patient Registration

Name:
First Last
Date of Birth:
MM slash DD slash YYYY
Prescribed Medications/Supplements:
Prescribed for:
Alcohol Use?
- Yes
- No
Tobacco Use?
- Yes
- No
Please list any known allergies:
Are you pregnant?
- Yes
- No
Any unusual eye history for self or family:
Tobacco Use?
- Yes
- No