• Welcome to Professional Family Eyecare

  • Patient Information

  • Eye Exam History

  • Primary Care Information

  • Family Eye/Medical History (Check all that apply)

  • If yes, please list which family member(s)?

  • Medical History

  • When did you start smoking?

  • If yes, how much do you smoke?

  • Eye Health History

    Have you ever experienced, been diagnosed, or treated for any of the following?
  • Consent To Provide Health Care Services To Minor Child

    Fill Out For Minors Only.
  • I,     (parent or legal guardian), give consent to Professional Family Eyecare to arrange, schedule, and/or provide health care services, including the administration of tropical anesthetic drops and a prescription for medicinal drugs, if needed, to     , as deemed necessary for the health and welfare of said minor child. This authorization is effective from the date of signature. 

    Minor Child's Name
          

    Signature of Parent or Legal Guardian
       

    Relationship to Child
       

    Pick a Date   

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