Northside Vision, LLC - Optometry in Boiling …

☐ Eye Infection Eye Injury ☐ Eye Strain ☐ Fainting spells, Blackouts. DOB: _____ Date of Last Eye Exam: _____ Name of your eye doctor: _____ Do you wear glasses: ☐ All the time ☐ Occasionally ☐ Reading ☐ Driving ☐ TV ................
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