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Patient History Form Patient Name Date Birth Date Referring Doctor If yes please explain 1. Please list medications you are taking including eye drops 2. Do you have any allergies to any medication?

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What is if yes please explain?

The question refers to a specific scenario or condition. If this condition is met, then further explanation or action may be required.

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The individuals or entities who meet the specific condition mentioned in the question are required to file. Further explanation may be provided depending on the situation.

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The purpose is to ensure compliance with regulations or requirements that are triggered by the specific condition mentioned in the question. Further explanation may be provided based on the situation.

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Specific information related to the condition mentioned in the question must be reported. Further details may be provided depending on the scenario.