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X Signature of patient or parent if minor Date Date of last eye exam // Do you wear glasses Yes or No Do you wear contact lenses Yes or No Doctor How old are the lenses If yes what kind Soft Hard RGP Disposable Daily wear Extended wear Are you interested in contacts Yes or No Are you interested in Laser Vision Correction Yes or No Medical History Including Present Medications You re Taking Do you or have had any of the following medical conditions If yes please explain include date of...
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Enter the patient's current age accurately.
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