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Patient Info Form

Sex: M F
New Patient
Returning Patient


No    Yes

 Yes     No

 Glasses     Contacts     Both     None    *Please note: Contact lens exam fees may not be covered by insurance*
 Blurred Vision
 Strain / Double Vision
 Vision Related Headaches
 Pain / Redness
 Flashes / Floaters
 Discharge
 Glaucoma
 Macular Degenration
 Cataracts
 Retinal Detachment
 Yes     No

 Yes     No
 Yes     No
 Yes     No
 Yes     No

Does anyone in your family have:

 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No


Please enter purpose of appointment / comments.