eca Eye Care Associates
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Last Name:   First Name:   MI:
Birthdate:    Male Female

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Is this visit for a:   medical problem, vision examination, or both
Do you wear contact lenses?   Yes No
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Do you need a referral to see a specialist?   Yes No
What is your vision insurance:
When would you like to be seen: Mon Tue Wed Thu Fri
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If you are having a life or sight threatening emergency call 911 or go to the nearest emergency room. If you need an urgent appointment, please call our office at 925-866-2020.