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WE ARE OPEN but due to COVID-19 our office will be providing ALL services by APPOINTMENT ONLY.
Please contact our office to book an appointment.

Located 1 block east from the corner of Dysart and McDowell
Right after Fry’s Market in Avondale, AZ

Home » New Patient Medical History Form-copy

New Patient Medical History Form-copy

New Patient Medical History Form-2018

Please note: This form must be completed in full before you can submit it.
If there is nothing to list, write “N/A” (not applicable).
  • iInclude which eye and date of occurrence(s)
    InjuryWhich eye?Date of occurrence 
  • The following SOCIAL HISTORY information is kept strictly confidential.


    Do you or an immediate family member currently have, or have had ever, any problems in the following areas? Please check YES or NO for you, and, if applicable, check FAMILY MEMBER and specify who (mother, father, sister, brother, etc).
  • Skin
  • Anxiety, Depression
  • Glands
  • Arthritis
  • Seasonal/Other
  • EYES

  • cataract/LASIK/RK
  • MM slash DD slash YYYY