San Bruno Eye Care Center

Patient Form

Basic Information

To 'Submit' form, all required fields in this section must be filled out.
Name(Required)
Sex(Required)
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Address
Allow Messaging

To 'Submit' form, please enter at least one method of contact.

Employer Info

Address

Other Contact Info

Visit Information

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First Visit

Eye Health

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General Health

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Do you smoke tobacco products?

Family History

High blood pressure
Diabetes
Glaucoma
Macular degeneration
Retinal detachment
Cataracts

Physician / General Practitioner

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Medications

Enter all medications taken, and for which condition each is taken
Medication
Condition
Allergies
Enter all medications or substances to which the patient is allergic

Please answer the following questions

Are you pregnant or nursing?
Do you have trouble driving at night?
Do you wear glasses?
Do you wear contacts?
Do you experience blur, headaches, or eyestrain with computer use?
Are you interested in laser (refractive) surgery to correct your vision? Yes No

Vision Insurance Information

Patient's relationship to insured
Primary Insured's Sex
MM slash DD slash YYYY

Other Insurance Information

Patient's relationship to insured
2nd Insured's Sex
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