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O. B. Patient s name // Email Sex M Street address Phone number City State Emergency Contact Women Only F Pregnant Zip Code How did you hear about us Emergency phone number Nursing Date of last eye exam Reason for your visit today check one routine eye exam contact lenses both other SOCIAL AND WORK HISTORY Work Status Hobbies Occupation Do you drink alcohol Yes No Marital Status Do you smoke Yes No PAST MEDICAL HISTORY Hypertension High Cholesterol Thyroid Disease Heart...
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