Minor Ailment Service - PSNC Main site

Signature (guardian signs IF patient is a minor): _____ Date: _____ NEW JERSEY EYE CENTER. MEDICAL HISTORY . PATIENT NAME_____ DATE OF BIRTH_____ ... LIST ANY SURGERIES YOU HAVE HAD: _____ Do you currently have any of the following MEDICAL problems? (Check those that apply) Loss of vision Blurred vision Flashes of light Loss of side vision ... ................
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