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S:\LINCOLN FORMS\Lincoln Front Office\New Patient Cataract Information\MEDICATION

SHEET.doc

Patient Name_______________________________ Date____________________

MEDICATION SHEET

PLEASE LIST ALL OF YOUR CURRENT MEDICATIONS, THE DOSE, AND HOW

MANY TIMES A DAY YOU TAKE THEM

Name of Medicine

Dosage Per Day

IF YOU NEED HELP FILLING OUT THIS FORM, PLEASE

BRING ALL MEDICATIONS WITH YOU TO YOUR APPT.

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