Patient Information Dr. Melman and Dr. Hodle
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Email address *
First Name *
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Last Name *
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Preferred Name
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Gender
Date of Birth ( Required )
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Address
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Phone (note: Cell or Landline) *
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preferred communication *
Occupation, special activities
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Employer or School
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Vision Plans (including ID #)
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Primary Medical Insurance (including ID #) *
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Secondary Medical Insurance (including ID # )
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Last exam date (estimate OK)
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Corona Virus Screen
Health Review( list of medical diagnoses: anxiety, attention deficit, diabetes, elevated bp, heart disease, high cholesterol, lupus, MS, strabismus, surgery, etc) *
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List of Current Medications *
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Current Concerns *
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