MEDICATIONS LIST - Lanter Eyecare
Patient Name: ________________________________________________
Date: ___________/___________/______________
Drug Name Strength How taken How often
|EXAMPLE: CELEBREX |100 MG |ORALLY |ONCE DAILY |
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Known Allergies Reaction Past Surgeries Date
|EX: PENICILLIN |RASH |EX: APPENDECTOMY |07-11-1977 |
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This form will be updated by you at every visit.
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