Eye Care Information Positive SSL Seal

    Page 1 of 5

  1. First Name(*)
    First Name is Required
  2. Last Name(*)
    Last Name is Required
  3. Date of Birth(*)
    / / Date of Birth is Required
  4. Address(*)
    Address is Required
  5. City(*)
    City is Required
  6. Postal Code(*)
    Postal Code is Required
  7. Phone Number(*)
    Please enter phone number in format 123-456-7890
  8. Work Phone Number
    Please enter phone number in format 1234567890 or 123-456-7890
  9. Email(*)
    Email Address is Required
  10. Sight N' Steps Location(*)
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  11.  

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  1. Medical History: Have you ever had any of the following? (Please check if yes)



















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  2.  

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  1. Medications (Please List):
  2. Medication 1.
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  3. Medication 2.
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  4. Medication 3.
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  5. Allergies (Please List);
  6. Allergy 1.
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  7. Allergy 2.
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  8. Allergy 3.
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  9.  

    Page 4 of 5

  1. Reason for Today's Visit?
  2. Do you have trouble seeing any of the following?



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  3. Do you? Or have you ever?


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  4. Have you ever had Surgey? If yes provide reason:
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  5. Have you required Hospitalization within last year?
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  6.  

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  1. Acknowledgement: By placing my initials and date I hereby give my permission to Sight N' Steps to examine and treat my eyes. I acknowledge that an Optometrist will charge a fees for services that is payable on completion on treatment.
  2. Acknowledgement Date(*)
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  3. Acknowledgement Initials(*)
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  4. Do you want to submit additional eye care information forms for family members (common information will be copied)?(*)
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  5. Please enter the numbers in the image(*)
    Please enter the numbers in the image
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