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Laser Vision Correction Cincinnati Ohio

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Medical History Questionnaire

Either fill out this online form below, or download and fill out the Medical History Questionnaire (PDF), and bring it with you on your next visit with us.

Please identify if you currently have or have
had any problems in the following areas.
"YES", please explain.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you answered "yes" to any question please fill out the following box with your information.
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