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Medical Registration Form

So that we can get an idea of your state of health, please fill out the questions below.

5. Reason for visit?
6. Last medicinal eye-check?
7. Are you currently pregnant?
> Are you still breast-feeding?
8. Do you have a contagious disease? (Hepatitis, MRSA, etc.)
9. Have you any allergies?
10. Are you affected by?
11. Any family eye diseases?
12. Did you have an eye injury?
13. Have you ever been cross-eyed?
14. Do you require a prescription?
15. Have you ever had laser surgery or been operated before?
16. Are you currently taking medication regularly? Please list these.
18. I request information about

We have received your form.

Thank you!

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