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Optical Fashions Eye Care Clinic Existing Patient Forms
Berenice
2023-02-24T15:56:31+00:00
Optical Fashions Eye Care Clinic Existing Patient Forms
Name
First
Last
Birthday
MM slash DD slash YYYY
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
Employer
Occupation
Insurance Company
If you do not have insurance please indicate with “None”
Member Name
First
Last
Member DOB
MM slash DD slash YYYY
Member Number
Was your last exam at Optical Fashions?
Yes
No
Would you like to be dilated at your exam?
Yes
No
We offer Clarus Photography which can be done instead or along with dilation to give the doctor a more complete view of your retinas. This does come with a charge that is non-submittable to insurance. Would you be interested in Clarus Photography?
Yes
No
If you are not a contact lens wearer are you interested in trying contacts?
Yes
No
List all medications/vitamins that you are currently taking
Any new allergies to medications or environmental allergies?
Are you pregnant or nursing?
Yes
No
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