Intake Form

Eye Exam $ 130. Eye Exam for Children 18 and under and Seniors 65 and Older -$30 (Balanced Billing with AB). If you have insurance, please present this with your from to predetermine your coverage
First Name
Last Name
Cell
Email
example@example.com
Address
Postal Code
GP NAME/MEDICAL CLINIC
Alberta Health Care
Insurance Name
Policy Number
Group ID
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that I am responsible for all fees charged, and if Alberta Health Care rejects any claims I will pay the full amount. (Select Box) : Privacy
Should be Empty: