Consent Form

    Dear Consenter:

    Prior to conducting either an Optometry Examination or Optician Consultation by Optician On Wheels and its Practitioners, we are required to obtain your Consent as the Patient, or where applicable, the one of your Corresponding Guardian.

    In this regard, in advance of the Scheduled Eye Examination Date, and to expedite the registration process, as the preferred method, please complete the following Consent Form to ensure that a spot has been reserved.

    Important Note: Please be advised that without receiving the Signed Consent Form via any of the provided methods of either online or hardcopy prior to the Scheduled Eye Examination Date, regretfully, with no exception, we will not be permitted to conduct Optometry Examination and or Optician Consultation on the Scheduled Eye Examination Date.

    Yours Truly,

    Optician On Wheels 1(888) EYEZ-2-GO 1(888) 393-9246 info@opticianonwheels.com www.opticianonwheels.com

    Section 1 - Facility Information

    Note:  Facility refers to the Senior Setting, Corporation, Educational Institute or any other Physical Location, which the service by the Optician On Wheels has been scheduled for.

    Name*
    Street Address*
    Province*
    City*
    Postal Code*
    Contact
    E-Mail
    Phone Number
    Section 2 - Patient Information
    Full Name*
    Date Of Birth*
    Gender*
    Health Card Number
    (Numbers Only & No Spaces)*
    Version Code
    (Letters at the end of the number)*
    Health Card Expiration Date*
    Name of Private Insurance Provider
    Private Insurance Card Number
    Private Insurance Card Expiration Date
    Resident of Facility
    or Student or Employee*
    Level of Mobility*
    1  -  Fully Mobile: Independently Mobile with No Restriction or need for Assistance 2  -  Semi Mobile: On Walker or Wheelchair or Need Assistance with Mobility 3  -  Immobile: Restricted to Bedside Visit
    Preferred Method(s) of Communication

    Email:

    Phone:

    Mail:

    Section 3 - Consenter Information
    If the same as patient, check the box and go to Section 5
    Full Name
    Relation to Patient
    Note: A copy of Power of Attorney or other documentation giving the above person the right to provide consent on behalf of the Patient will be required to be provided at the time of the Eye Examination.
    Section 4 - Communication Method with Consenter
    Preferred Method(s) of Communication (Provide information; e- mail address, phone number and area code and full mailing address with postal code)

    Email:

    Phone:

    Mail:

    Section 5 - Reason For Eye Examination Visit

    Note: Check all applicable and provide comments, if any*

    If selected Other (Be as specific as possible)

    Section 6 - Category of Eye Examination

    As part of the Basic Examination, the Optometrist is to examine the front and back of eyes of a Patient. Otherwise, tissues and structures inside the eyes may be required to be examined looking for eye diseases such as cataracts, glaucoma or macular degeneration, as well as tears in the retina, bleeding and tumours, where to diagnose them, Comprehensive and Comprehensive Plus Examinations are required. In general, depending of the Eye Examination Category, it may include:

    • Anterior Segment Assessment
    • Posterior Segment Assessment
    • Tonometry & Diagnostic Imaging
    • Analysis and Treatment
    • Reviewing Medical and Case History
    • Visual Acuity and Function
    • Visual Fields
    • Binocular Vision Efficiency
    • Determining the eye glass prescription; Refraction

    In specific:

    • Basic:Checking the Front and Back of the Eyes & Eyeglasses Prescription
    • Comprehensive:Basic AND Fundus Camera & Wavefront Aberrometry Assessment
    • Comprehensive Plus:Comprehensive AND BioPhotonic Health Scanner

    IMPORTANT NOTES:

    1- In case of Senior Community/Retirement Home/Nursing Home, to determine the most appropriate Examination Category, the facility is to release, prior to the Examination Day, the Patient’s Health and Medication(s) Information on a Specific Form provided by and to Optician On Wheels.

    2- Considering the varying condition of each patient, and based on the initial findings, additional diagnostic testing may be recommended by the Optometrist, at the extra cost.

    Select a Category of Eye Examination (Add comment, if necessary)*

    Section 7 - Optometry (Eye Examination)

    As part of the Eye Examination, it may be required to include a Dilated Fundus Exam, if the Optometrist determines that it is necessary to evaluate the eye health. This is accomplished by placing drops in the eyes that make the pupils become larger, providing for a through examination of the interior portion of the eye.

    Dilated Fundus Exam require drops to be administered. These drops will add approximately 30 additional minutes to the eye exam and it will take 4-6 hours for it to wear off. During this time, patient may experience blurred vision and light sensitivity. So, the patient may require assistance reaching the destination thereafter. *

    Section 8 - Optician (Prescription Analysis & Eyewear)

    In cases of the Prescription Eye Glasses or Contact Lenses, Optician is required to review the Prescription, Conduct Necessary Measurement and Assist with Selecting and or Recommend the most appropriate Product(s).*

    Section 9 - Billing and Insurance

    Optician On Wheels will make every effort possible to bill the exam to Patient’s Health or Vision Insurance, including the Private One. However, if the claim is denied and or Optician On Wheels is unable to process the claim further, the total amount, including all applicable taxes, will be billed directly to Patient and it is the Patient’s Responsibility to pay any balance due to the Optician On Wheels.*

    Section 10 - COVID-19 Health History

    Note: The information below are related to the Patient, and may be provided by the Consenter of the Form

    Currently experiencing any of these symptoms: Fever and/or chills, Cough or barking cough (croup), Shortness of breath, Decrease or loss of taste or smell, Muscle aches/joint pain, Extreme tiredness, Nausea/vomiting, and/or diarrhea and or Any/all that are new, worsening, and not related to other known causes or conditions you already have.*

    In the last 10 days, tested positive or waiting for any test results, received a COVID Alert Exposure Notification on your cell phone.*

    In the last 10 days, have been told to isolate by a doctor, health care provider, or public health unit.*

    In the last 10 days, had close contact with a confirmed case of COVID-19.*

    Sharing dwelling with someone, who is currently, experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? Been told to isolate by a doctor, health care provider, or public health unit.*

    If response to any questions in this section is Yes, provide explanation.

    Consent Confirmation & Signature

    By signing here, I confirm that I have read, understood and agreed with all Sections mentioned in this Consent Form.

    Full Name*

    Signature*

    Note: Please use the Mouse or Pointer on the Touch Screen, if available, to draw your signature in the provided area. To modify or change your Drawn Signature, please use provided Clear button.
    Date *