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Custom Contacts/Scleral Myopia Control Dry Eyes

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Home » Eyeglasses & Contacts » ZEISS Digital Lens » Patient History Form

Patient History Form

  • WELCOME TO OUR OFFICE

    Please help us provide you the best possible care by providing the following information.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (If child)
  • (If child)
  • MEDICAL HISTORY

  • YesNo
    Allergies
    Arthritis
    Asthma
    Cancer
    Diabetes
    Eye Injury
    Eye Disease
    Heart Disease
    High Blood
    Lazy Eye
    Eye Surgery
    Cataracts
    Lung Condition
    Glaucoma
    Thyroid
    Other
  • CURRENT MEDICATIONS

  • FAMILY MEDICAL HISTORY

  • Do You...

  • (a nonsurgical way to get rid of contacts and glasses)
  • Hrs./week
  • Do You Experience...

  • How did you first hear about our office?

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Due to COVID-19, our office is closed for all routine eye care services. We will be seeing emergency eye care needs only. We have staff answering phones during limited hours. If you have less than a 3 month supply of contact lenses, please contact us at 704-825-9002 and we will help with your contact lens needs. Thank you and stay well!