First Name*
Last Name*
Suffix*
Street Address*
City*
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ZIP/Postal Code*
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Phone Number*
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Email*
Date of Birth*
Occupation
Health Card
Eye History
Medical History
When approximately was your last eye exam?
Where did you get your last eye exam?
When approximately was your last physical exam?
Who is your primary care physician?
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from
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