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Patient History Form

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  • New Patient: Please fill out the information below and Welcome to TSO Custer Creek.

    Returning Patient: If you are a returning patient, please indicate any changes below or new medical conditions.
  • Health Insurance Information

    WHILE THE ASSESSMENT AND / OR TREATMENT OF AN EYE DISEASE, EYE PAIN, AND/OR VISION DISTURBANCE IS NOT COVERED BY YOUR VISION INSURANCE, IT MAY BE COVERED BY YOUR PRIMARY MEDICAL INSURANCE.
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  • Review of Symptoms

    Do you currently have any of the medical conditions below? Check All that apply.
  • Please Click (+) sign to the right to add more information if needed.

  • PLEASE SELECT NONE IN EACH CATEGORY IF THE CONDITIONS LISTED BELOW DOES NOT APPLY TO YOU.
  • MEDICATIONS/ ALLERGIES

  • Please Click (+) sign to the right to add more information if needed.
    NameDosageStrengthFrequency 
  • Please Click (+) sign to the right to add more information if needed.
  • SOCIAL HISTORY

    (CONFIDENTIAL INFORMATION)
  • FAMILY HISTORY

    Check below and specify who in your family (parent, sibling, grandparents) have any of the following:
  • Designation to Release Information of Care

    TSO Custer Creek have my permission to discuss the management and treatment options of this patients’ ocular health to the individual listed below.
  • NameDOBPhone 
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  • Acknowledgment of Notice of Privacy Practices

  • Visual Eye Health, PLLC dba Texas State Optical Custer Creek
    3501 CUSTER PKWY STE 105
    RICHARDSON, Texas 75080
    469-929-2900

    The law requires that Visual Eye Health, PLLC dba Texas State Optical Custer Creek make every effort to inform you of your rights related to your personal health information.

  • I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
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  • If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.
  • Patient Financial Responsibility Statement

  • Our primary mission is to provide you with quality, cost effective, vision care.

    I understand that payment for all services rendered is due at the time they are performed, and that all services provided are non-refundable.

    I understand that all glasses purchased at TSO Custer Creek are custom made medical devices whose production is started for me immediately upon purchase, and that all glasses purchased are non-refundable.

    I understand that contact lenses purchased at TSO Custer Creek are ordered for me immediately upon purchase, and that all contact lens purchased are non-refundable.

    I understand that TSO Custer Creek will help facilitate my insurance transaction, but that ultimately it is my responsibility to know the terms and conditions of my insurance coverage. If you have any specific questions regarding your insurance plan, it may be best to contact your insurance provider directly using the member services phone number listed on your card.

    I understand that TSO Custer Creek will make only reasonable efforts to process my insurance claim for services rendered and/or products ordered on my behalf.

    I understand that if for any reason payment for provided services and/or products is denied to TSO Custer Creek by my insurance, I will receive a bill in the mail and I am responsible for paying for theses services and/or products because they have already been provided to me. Your insurance plan may refuse payment of a claim for some of the following reasons:

    1. You have not met your calendar year deductible
    2. The health/vision plan was not in effect at the time of service
    3. You have other insurance which is primary to the insurance you provided
    4. A referral was required for services to be provided

    I request that payment from my insurance company be made to TSO Custer Creek for any services or products furnished to me by this provider.

    I authorize TSO Custer Creek to release any personal or medical information to any insurance company or their agent that is necessary for determining my benefits or collecting payment for services rendered.

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Prior to your visit, please:

Upon Arrival:

Thank you for your cooperation as we continue to protect our patients and staff, and please feel free to call us with any questions.

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