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Our Team
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Eye Care Services
Low Vision
Glasses & Contacts
Insurance Info
Our Team
Contact Us
New Patient Form
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Contact Information
*This form is only for patients who already have an appointment booked*
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone Number
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Email Address
Personal Information
Date of Birth
*
MM slash DD slash YYYY
Gender
*
< select >
Female
Male
Preferred Language
*
< select >
English
Spanish
French
Japanese
Decline to specify
Marital Status
< select >
Divorced
Legally Separated
Married
Single
Widowed
Other
Marital Status - Other
Please provide your marital status.
Employment Status
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Employed Full-Time
Employed Part-Time
Not Employed
On Active Military Duty
Retired
Self-Employed
Student Full-Time
Student Part-Time
Other
Employment Status - Other
Please provide your employment status.
Employer
Occupation
How were you referred to our office?
< select >
Friend or Family
Family Doctor
Ophthalmologist
Insurance Company
Newspaper
Television
Radio
Received Mailing
Internet
Other Optometrist
Other
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
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Email
Postal
Telephone
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
No
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
No
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
No
Are you currently COVID +'ve or awaiting COVID test results?
*
Yes - if yes, please contact our office
No
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
No
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.
Comments
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