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Patient Information

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Patient Name
Address
Preferred Communication

Responsible Party Information

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Responsible Party's Name
Address

Primary Insurance

Insured's Name
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Insurance Company Address

Secondary Insurance

Insured's Name
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Insurance CompanyAddress
Are you currently on food stamps?
Referrals - Shelters and Organizations only
Firm/Organization/Name
Phone
Address
Contact Person
 

Patient History

Name
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Current Medications

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
Name of Drug
Dose (include strength & number of pills per day)
 
Drug Allergies

Past Medical History

Do you now or have you ever had:
Family Ocular Medical Hx
Do you drink alcohol?
Do you use tobacco?
Do your hobbies or work put you at risk of an eye injury?
Do you have problems in the following areas?