Welcome Back to Clarity Eye Care!

Please complete the following information to help us understand you and your eyes.
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Date of Exam
Legal first name
Middle initial
Last name
What should we call you?
She/her, He/they, etc.
(choose all that apply)
(approximate date is OK)

Are you CURRENTLY or RECENTLY experiencing any of the following with your eyes?

(for example, computer monitors or the dashboard in your car)

Personal Medical History: Have you ever been diagnosed with any of the following? (If no, please check ‘none’)

Please list any and all medications that you are currently taking, INCLUDING prescription and non-prescription medications, creams, and eye drops, vitamins, and supplements, along with what you are taking them for. If you are not taking any medications, please list 'none'

if you are not using any medications or supplements, please type 'none'

Family history: Have any of your blood relatives (parents, grandparents, children, living or deceased) been diagnosed with any of the following:

Please list the name(s) of any other adult(s) you would like to have access to this patient's medical information for any reason
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