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Patient Data

Physician: *

Date

Physician's Email *

Phone Number *

WhatsApp # is preferred

Patient:

*surgery not reccomended during pregnancy

Age

Sphere:

Eye

Cylinder:

Axis:

Surgical Technique: *

Other

Surgical Procedure History (check all that apply)

Cross-Linking

Date of Cross-Linking Procedure//

Lasik

Lasik

Date of Lasik Procedure//

Corneal Transplant

Corneal Transplant

Date of Corneal Transplant //

Cataract

Cataract

Date of Cataract Procedure//

Required PDF Attachments: *

Click or drag a file to this area to upload.

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