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Eye History
Contact Lens Wearers only:
Medical History:
*This field is required
*This field is required
Family Medical History
*Required
Does anyone in your family have any medical conditions?
Family Eye History
*Required
Does anyone in your family have any of these eye conditions?
Review Of Systems
*Required
Social History
*Required
Acknowledgment of Notice of Privacy Practices
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view our HIPAA Privacy Policy*
The law requires that Doctor's Eye Clinic make every effort to inform you of your rights
related to your personal health information.
By my signing below, I acknowledge one of the following:
Or
Or
I HAVE READ AND UNDERSTAND THIS FORM AND I AM SIGNING IT VOLUNTARILY:
Name, Relation, Address, and Phone Number of those you authorize our office to release your private health information: