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New Patient Registration 


Please Fill out both pages of the form.  After filling out first page, please click next to fill out the second page.

1. What is the reason(s) for your visit? Pleae select all that apply.
3. What type of eyeglases do you own? Please select all that apply.
4. Do you have any medical codition(s)? If yes, please select all that apply:
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