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Curtis Vision introduce Orthokeratology or Ortho-K to their Armagh Street branch, ortho-K vision corcontact lenses

Patient Information Form

 
The following information is required to enable Curtis Vision to provide the best eye care services possible.  Please complete as many areas as are appropriate.  All details provided will be treated in the strictest confidence and will only be used by Curtis Vision for the purposes for which they are intended.
Fields marked with * are required

Preferred Title: *
First Name: *
Middle Name: *
Last Name: *
Home Address: *
Postal Address: (if different)
Date of Birth: *
Gender: *
Family Doctor: *
Business Address:
Home Telephone: *
Business Telephone:
Mobile number:
Email:
Occupation:
YESNO
Do you receive any welfare benefits? *
Have you ever had your eyes examined? *
If yes then where and when
Were you referred for examination by: *
Did you hear about us through: *

 


 

CASE HISTORY

Do you wear Spectacles or Contact Lenses? *
What is the biggest problem you are having with your EYES or your GLASSES / CONTACT LENSES at the present time? *
Have you ever had an EYE INJURY, EYE INFECTION that needed treatment or EYE SURGERY? *
If yes please state
Please state any MEDICAL PROBLEMS or PRESENT ILLNESS: *
Please list ANY MEDICATION/S you are currently taking:
Are you ALLERGIC to anything? This also includes MEDICINES! *
If yes please state:

At times, the optometrist may deem it necessary to refer you to another health professional.  A referral will only occur with your permission.

I agree to allow relevant medical and visual history to be provided to the other health professional when required. *
 

 

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