New Patient Form | Acton Eyecare

Contact Information

*This form is only for patients who already have an appointment booked*

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Phone Number*

Email Address

Personal Information

Date of Birth*

MM slash DD slash YYYY

Gender*

Preferred Language*

Marital Status

Marital Status - Other

Please provide your marital status.

Employment Status

Employment Status - Other

Please provide your employment status.

Employer

Occupation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Eye History

Please check off any current conditions you suffer from:

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare/Light Sensitivity

Tired Eyes

Amblyopia (lazy eye)

Burning

Dryness

Watery Eyes

Eye Pain and/or Soreness

Foreign Body Sensation

Infection of Eye or Lid

Itching

Mucous Discharge

Drooping eyelid(s)

Redness

Sandy or Gritty Feeling

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes

What glasses do you own?

Single Vision

Bifocals

Safety Glasses

Backup Glasses

Progressive

Trifocals

Sports Glasses

Sunglasses

Other

Other glasses:

How many hours a day do you use a computer?

How many inches away do you sit from your screen?

Please check off any current conditions you suffer from:

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don’t have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

What is your typical wearing schedule? In days per week:

Please check off all that apply to you:

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

Medical History

Have you expereinced any flu-like symptoms (fever, chills, etc) over the past 14 days?*

Yes - if yes, please contact our office

Are you currently COVID +'ve or awaiting COVID test results?*

Yes - if yes, please contact our office

When, approximately, was your last eye exam?

Where did you get your last eye exam?

Who is your primary care physician?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Private Health Insurance

Please bring all insurance cards with you to your appointment.

Will you be using private health insurance to pay for a portion of your eye exam and/or eyewear?*

Yes

If "yes", please type the name of your provider*

***Please bring all insurance cards and information to your examination. Dates for insurance eligibility are the responsibility of the patient so please check with your provider before your examination.***

If you have coverage through another plan/organization, please fill in the details below.

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