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Patient Name: Email: Male/Female (CIRCLE) DOB: Do you want a reminder for next year's exam: Y/ N (CIRCLE)Address: City State Zip code Phone #: Employer: Occupation: Date of Last Eye Exam: Last Eye
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Start by locating the section on the form that requires you to fill out the patient's name.
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Look for a circle or box specifically labeled 'Male' and 'Female'.
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If the patient is male, carefully fill in the circle or box next to 'Male' using a pen or pencil.
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If the patient is female, carefully fill in the circle or box next to 'Female' using a pen or pencil.
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