New Patient Intake Form

New Patient Registration
To assist us in providing the best quality care, please fill out this form. All personal and health information is confidential.
Today's Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any symptoms of COVID-19?
Are you living with someone that has symptoms of COVID-19?
Have you been in contact with a confirmed case of COVID-19?
Have you travelled outside of Ontario within 14 days?
If you answer Yes to any of the above questions, we cannot schedule an in-person appointment for you at the moment. Instead, we are now offering telehealth virtual appointments for consultations and to screen and triage urgent care appointments.
The appointment does require the patient to use a digital device with a video camera. If you would like to make a virtual appointment, please continue to fill out the rest of the intake form and we will get back to you as soon as possible.
Patient Name
First NameMiddle NameLast Name
Address
Street Address
Street Address Line 2
CityProvince
Postal CodeCountry
Phone Number
Area CodePhone Number
Alternate Phone Number
Area CodePhone Number
E-mail
Date of Birth
DayMonthYear
Health Card Number (OHIP)
Version Code
Family Doctor's Name
Occupation
Hobbies
Are you taking any medications or eye drops currently?
If yes, please list it here
Do you have any known eye condition or diseases?
If yes, please list it here
Do you have any family history of eye diseases?
If yes, please list it here
Have you had any eye injuries or surgeries?
Do you have any allergies?
Smoking History:
For women only - Are you pregnant or nursing at the moment?
When was your last eye examination?
Have your eyes been dilated before?
What is the main reason for your visit with the Optometrist?
Contact Lens History
What type of lenses do you wear
Frequency of Wear (# of Days per week)
Contact Lens Solution
RECOMMENDED RETINAL SCREENING
We recommend retinal photography as an integral part of your dilated eye exam. A retinal photo is a permanent record for your medical file,which enables us to make important comparisons if potential problems show themselves at a future examination. These photos capture the optic nerve, macula, and retinal arteries and veins and may detect conditions such as glaucoma, diabetes, high blood pressure, high cholesterol, and macular degeneration.
Retinal Photo ($25)
Privacy Policy

Our optometry clinic is committed to collecting, using and disclosing your personal information in a responsible manner. The privacy practices of our office are in accordance with all federal and provincial law and regulations.
I understand that my personal information will be kept confidential in accordance with The Registered Health Practitioners Act and Personal Information Protection and Electronic Documents Act (PIPEDA). I understand that for the purposes of communication between this office and the patient that I will periodically receive e-mails.
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New Patient Registration