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Salisbury MD - Berlin MD - Pocomoke, MD | (410) 749-9290

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MEDICAL HISTORY

Date

Name

Social Security #

Age

Gender

REASON FOR VISIT

EYE/ENT SYSTEM REVIEW (PLEASE CHECK ALL THAT APPLY) * Required

EYE PAIN

LIGHT FLASHES

STRAIGHT LINES APPEAR CROOKED

BLURRED VISION

ITCHY/WATERY EYES

DIFFICULTY WITH NIGH VISION

GLARE/LIGHT SENSITIVE

DRY EYES

SINUS/NASAL CONGESTION

DRY THROAT

OTHER

About Us

Peninsula Eye Center's Board Certified Ophthalmologists and Board Certified Optometrists make sure your needs and expectations are placed at the highest level.

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Types of Services

Eye Examinations

Glasses

Contact Lens Services

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Medical Eye Care

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Main Office

Peninsula Eye Center

101 Milford Street

Salisbury, MD 21801

(410) 749-9290

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