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Advanced Family Eye Care
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Insurance Information for Authorization of Benefits
Consent to Treatment
Medication list
New Patient form
New Patient form
New Field1
*
First Name
New Field2
*
Last Name
Initial
*
Middle Initial
DOB
*
Date of birth.
Address
Street , city, state, zip
phone number
please provide best contact info
Email
Primary Care doctor
Doctor name and practice
emergency Contact
Name and contact info
preferred method of contact
*
Email
Phone
text
All the above
please select the preferred method of contact
* Required field
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