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Home » About TSO In Portland » Welcome to the office of Dr. Shandley

Welcome to the office of Dr. Shandley

Thank you for choosing us for you eye care needs. We are delighted to have you as a patient and appreciate the confidence you have placed in us. Please take a moment to complete the following information. Any information we already have on file will appear on this form. Please review all completed areas to ensure that the information we have is current and accurate. If you have any questions, please do not hesitate to ask.
Appointment Date
MM slash DD slash YYYY
Name
First Middle Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Occupation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Home Phone
Work Phone
Email Address
Spouse or Parent(s) Name(s)
Primary Care Doctor
Primary Care Dr. Phone Number
Person Responsible for Account
Responsible Party SS Number
Date of Birth
MM slash DD slash YYYY
Employer/School
Responsible Party’s Employer
Responsible Party’s Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Preferred method of contact:
- Text
- Email
- Landline
IF NO CHANGES TO YOUR INFORMATION, PLEASE INITIAL HERE
Vision Insurance Information
Company
ID#
Group
Subscriber’s Name
Subscriber’s DOB
MM slash DD slash YYYY
Subscriber’s Employer
Patient Relationship to Insured
- Self
- Spouse
- Child
Medical Insurance
Company
ID#
Subscriber’s Name
Subscriber’s DOB
MM slash DD slash YYYY
Authorization for dilation
In the process of today’s examination, the doctor may recommend dilation for further examination of your eyes. Dilation may not be part of the routine examination, thus it may be an additional expense. If so, do you wish to be dilated today?
- Yes
- No
Authorization to Release Medical Information
I authorize Robert M. Barton, Jr. O.D. to release/request medical information on my behalf to/from any entity to assist in my medical care per my request. This assignment will remain in effect until revoked in writing.
- Yes
- No
Patient/Guardian Signature
Date
MM slash DD slash YYYY

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Hours & Directions

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:00 AM - 5:30 PM
Saturday: Closed
Sunday: Closed

1540 Wildcat Dr
Portland, TX 78374

Book Appointment Call (361) 210-3522

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Texas State Optical - Located at 1540 Wildcat Drive, Portland, Texas 78374 Phone: 361-643-1516 www.portlandtso.com

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