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PLEASE READ COMPLETE ALL QUESTIONS All Information is Strictly Confidential. Name Date of Birth Preferred Name SS if using insurance Address Phone E-mail Thank you for choosing The Eye Center Please choose your primary reason for today s visit o Annual eye exam o Annual exam for contact lenses o Diabetic eye exam o Eye Injury please explain o Follow up/Testing Additional concerns When was your last eye exam Do you wear glasses Yes No Are you interested in new glasses Yes No How old are your...
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