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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

New Patient Medical History Form

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).
  • Add a new row
  • iInclude which eye and date of occurrence(s)
    InjuryWhich eye?Date of occurrence 
    Add a new row
  • The following SOCIAL HISTORY information is kept strictly confidential.

  • REVIEW OF SYSTEMS

    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