Patient Information
First Name*
Middle Name
Last Name*
Date Of Birth*
Gender*
MaleFemaleOther
Health Card Number (Numbers Only & No Spaces)*
Version Code (Letters at the end of the number)*
Health Card Expiration Date*
Insurance Name / Policy Number
Preferred Method(s) of Communication
Email:
Phone:
Mail:
Read each statement. Check if true
I am pregnant
I have difficulty with night vision or night driving.
I am excessively bothered by sunlight, bright tights, or glare.
I spend time at a computer.
I am troubled with frequent headaches.
I have had a recent illness or been hospitalized in the last 2 years.
I have environmental allergies, sinus trouble, or hay fever.
I am allergic to medications.
I have had an eye infection. eye injury, or eye surgery (including Lasik).
I have had a head injury in the past
I experience flashes of light.
I use eye drops.
I currently have double vision.
I Have worn contact lenses in the past but no longer wear them currently.
I currently wear contact lenses.
MEDICAL AND OCULAR HISTORY
Check "yes" if applicable. Check "no" if not applicable.
You
Blood
Relation To Patient
Diabetes
YesNo
High Blood pressure
Heart Problems
Asthma
Retinal Detachment
Blindness
Lazy or Crossed Eyes
Glaucoma
Macular Degeneration
Other ocular(eye) problems
Other general health problems
List any medications you are currently taking (including aspirin, Birth control, and OTC medications)
Signature*
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Date *