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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).
  • 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
  • Date Format: MM slash DD slash YYYY


We are now scheduling Routine Eye Exams

We will be following the CDC guidelines to ensure the safety of our patients and our staff while we transition back to normal operations.

If you have an eye emergency, please contact us at any time.