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Patient Information Form and Pen

InfantSEE Form

Step 1 of 3

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  • Eye History

  • Developmental and Health History - Pregnancy

  • Developmental and Health History - Delivery

  • Developmental and Health History - Medical

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  • Include the type of illness, age at the time, and whether the illness was mild, moderate, or severe.
  • Family History

  • List the relation and type of problem.
  • Acknowledgement

  • I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of my child's eyes and vision. I understand that the InfantSEE™ vision assessment is without charge. If further services or treatments are recommended, I may choose any eye professional to provide those services.
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