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Patient History Form

Welcome to our office. Please take a moment to complete this form so we may help care for your eye health needs. Privacy of personal
information is very important to us. We will only use the information necessary for the optometric services and products we provide.

Have you experienced any of the following (Please Check)

Headaches/ MigrainesOcular Dryness or IrritationDouble VisionEye SurgeryEye Injury

Ocular/Medical History(Please check all that apply)