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:*
Read each statement. Check if true
on I am pregnant.
on I have difficulty with night vision or night driving.
on I spend time at a computer.
on I am troubled with frequent headaches.
on I have had a recent illness or been hospitalized in the last 2 years.
on I have environmental allergies, sinus trouble, or hay fever.
on I am allergic to medications.
on I have had an eye infection. eye injury, or eye surgery (including Lasik).
on I have had a head injury in the past.
on I experience flashes of light.
on I use eye drops.
on I currently have double vision.
on I Have worn contact lenses in the past but no longer wear them currently.
on I currently wear contact lenses.
MEDICAL AND OCULAR HISTORY
Check "yes" if applicable. Check "no" if not applicable.
Diabetes*
YesNo
High Blood pressure*
Heart Problems*
Asthma*
Retinal Detachment*
Blindness*
Lazy or Crossed Eyes*
Glaucoma*
Macular Degeneration*
Type of eye care required*
Eye ExamPrescription Eyeglasses (if needed)Both Services
Other ocular(eye) problems
Other general health problems
List any medications you are currently taking (including aspirin, Birth control, and OTC medications)
Appointment Date *
