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Medical History Form

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Patient's Name
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Personal Medical Information:
Do you have problems with any of these systems? If Yes, please check box.
Are You In Good Health
Do You Take Medications?
Name
Any allergic reactions to medications or other substances?
Do you have any of the following?
If Yes, please check box.
Please Explain
Please check Yes or No, if you smoke?
Please check Yes or No, if you Drink?
Please check Yes or No, if you Drink?
Do you have family history of any of the following?
If Yes, please check box.
Please sign below that you have reviewed all information above and it is correct to the best of your knowledge.
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Advanced Eye Care Center

4025 W Bell Rd, Suite 10
Phoenix, AZ 85053

602-978-4025
602-843-7101
[email protected]
(Do not send personal health information by email.)

technological advances
We are Proud to Provide Co-Management of Lasik and Cataract Surgeries