*
Denotes Mandatory Field
Name
*
First
Last
Date of Birth
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
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1922
1921
1920
Year
Gender
*
Male
Female
Non-Binary
OHIP Number
*
Required for all OHIP eligible exams.
Home Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Email
*
Phone Number
*
Format: (000) 000-0000.
Preferred Contact
Phone
Email
Family Doctor
What type of vision correction do you use?
*
Glasses
Contact Lenses
None
What is the purpose of your visit?
*
Dry Eyes
Need Contact Lenses
Need Glasses
Flashing Lights / Floaters
Sudden Vision Loss
Myopia Management
Headaches
Red Eyes
Routine Checkup
Other
Provide details:
*
What year was your last eye exam?
*
Are you being treated or monitored for any of the following health conditions?
*
Rows
Yes
No
Diabetes
High Blood Pressure
Stroke
Heart Disease
Cancer
Lupus
Arthritis
High Cholesterol
Hearing Loss
Dementia
Epilepsy
Multiple Sclerosis
Asthma
Autism
Are you being treated or monitored for any of the following health conditions?
*
Yes
No
Please list the health conditions that you are being treated or monitored for.
Please list all medications you are currently taking:
Have you had eye surgery?
*
Yes
No
Please provide details about the eye surgery or surgeries you have had in the past.
Do you use prescribed or over the counter eye drops?
*
Yes
No
Please list the prescription or over the counter eye drops that you use, and please bring them to your visit.
Have you been diagnosed with:
*
Rows
Yes
No
Cataracts
Glaucoma
Macular Degeneration
Keratoconus
Strabismus / Squint
How did you hear about us?
*
Doctor
Internet
Friend/ Family
Their name (optional)
Will you be bringing a translator to your appointment?
*
Yes
No
Policy #: Contact your insurance provider to determine your coverage.
I give permission to Dr. Sciberras' staff to make direct claims to my insurance provider.
Yes
No
Submit
Should be Empty: