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**PLEASE REVIEW THE PATIENT PRIVACY PRACTICES AND FINANCIAL POLICY PRIOR TO COMPLETING THIS FORM

Patient History Form

Your Information

Insurance Information

Medical/Family History

Review of Systems

Please indicate below if you currently have problems with the following conditions. If you are being treated for a condition, but the condition is controlled by medication, please select the condition.

Social History

Ocular History--Are you Currently Experiencing?

Additional Ocular History

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