PATIENT INTAKE FORM

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EyeWorld Optometry
905.597.7898

HOME
ABOUT US
EYE CARE SERVICES
EYEWEAR
BOOK AN APPOINTMENT
- PATIENT INTAKE FORM
- Covid-19 Self Assessment
ORDER CONTACTS

HOME
ABOUT US
EYE CARE SERVICES
EYEWEAR
BOOK AN APPOINTMENT
- PATIENT INTAKE FORM
- Covid-19 Self Assessment
ORDER CONTACTS

PATIENT INTAKE FORM
Please fill out the form below
All field marked * are mandatory questions.

First Name*

Last Name*

Date of Birth (MM-DD-YYYY)

Home Phone Number*

Cell Phone Number

Email Address*

Street Address*

City*

Province/State*

Postal/Zip Code

Are you fully vaccinated?*

You’re considered fully vaccinated two weeks after you get your second dose of a messenger RNA (mRNA) vaccine, such as Pfizer-BioNTech or Moderna, or two weeks after a single dose of the Janssen/Johnson & Johnson vaccine. We use this information to be informed about our patients entering our clinic and to follow the clinic's procedure to provide a safe environment for our doctor(s), staff, and our patients.

Yes, I am fully vaccinated.No, I am NOT fully vaccinated.I would rather not disclose my vaccination status.

Have you in the past 14 days:*

1. Travel outside of Canada2. Presence of symptoms such as fever or cough or shortness of breath3. Close contact with a confirmed or probable case of COVID-194. Close contact with a person with acute respiratory illness who has been to a COVID-19 impacted area5. If none of above, checkmark this box

OHIP Card #:

Ontario Health Insurance number and version code

Who is your family doctor?

1. What is the reason(s) for your visit? Please select all that apply.*

Routine/annual eye examinationEye ProblemOrtho-K Dream Lens ConsultationRGP or GP Contact lens Service including Fitting & purchaseSoft Contact Lens prescription/fittingShop for Eyeglasses/sunglasses/safety glassesLaser Surgery Consultation and evaluationVision TherapyOther

1a. If you answered Other to #1 or need to explain further, please describe below:

2. When was your last Eye Examination?

3. Do you currently own prescription glasses?

If yes, check all types of glasses you own

Distance onlyReading onlyProgressives/BifocalSafety glassesSports EyewearBackup GlassesComputer/Task GlassesPrescription SunglassesNon-prescription SunglassesAnti-fatique Glasses

3A. Do you wear specialty contact lenses such as Ortho-K lens or Dream lens?

YesNo

4. How many hours in a day are you looking at a screen? (Computer, mobile, etc)

5. Have you had any eye surgery or eye injury? If yes, describe;

6. Please check mark current medical conditions that apply to you:

GlaucomaCataractsDiabetesRetinal DetachmentCrossed/Lazy EyesMacular DegenerationHigh Blood PressureHeart ProblemsStrokeThyroid ConditionOther

If you selected Other from question #6, please describe your medical condition:

Describe your current medical condition.

7. Are you currently under the care of a physician for any medical condition?

8. Please list any medication you are currently taking

9. Any family history of eye health problems?

10. Any Family history of medical conditions?

11. Are you allergic to any medication? If Yes, list the medications.

12. What is your occupation?

13. What hobbies do you enjoy?

14. What brand of contact lens do you wear?

Skip if you don't wear contact lens

15. How often do you replace or dispose your contact lenses?

Skip if you don't wear contact lens

16. What brand of solutions do you store your contact lenses in?

Skip if you don't wear contact lens

17. What is your typical soft contact lens wearing schedule?

____________ Hours/Day, __________Days/Week (Skip if don't wear contact lenses)

18. Please checkmark if it applies to you:

Skip if you don't wear contact lenses

I am having problems with the vision when wearing my contact lensesI am having problems with the comfort of my contact lensesI am interested in refractive laser surgery

A 24 hour notice is required for all appointment cancellations. A cancellation fee will be charged for all missed appointments without 24 hour notice. The information that I have given on this Intake Form is accurate and complete to the best of my ability. I understand that my information will remain confidential unless allowed or required by law. When applicable, I acknowledge that I am responsible for the full cost of my appointment, payable at the same time as services are rendered. Do you agree to the Cancellation Policy Agreement?*

YESNO

At EyeWorld Optometry, we responsibly uphold your right to privacy and respectfully request your consent to continue to stay in contact with you to remind you when it is time to review your eye and vision care needs and through our periodic email and text messages from EyeWorld Optometry. In order to provide proper eye care and services, EyeWorld Optometry will collect some personal information including your contact numbers, date of birth, address, OHIP number, medical conditions and medications. This information may be shared in the event that you are referred to another health care provider. Do you agree to this Patient Privacy Protection agreement? *

YESNO

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ADDRESS
7181 Yonge Street, Unit 138
Thornhill, ON L3T 0C7

CONTACT

P: (905)597-7898

F: (905)597-7899

Email: [email protected]

HOURS OF OPERATION

Mon 10:00 - 6:00

Tues 10:00 - 2:00

Wed 10:00 - 7:00

Thurs 10:00 - 6:00

Fri 10:00 - 7:00

Sat 11:00 - 5:00

Sun Closed

BOOK AN APPOINTMENT

HOME
ABOUT US
EYE CARE SERVICES
EYEWEAR
BOOK AN APPOINTMENT
ORDER CONTACTS

EyeWorld Optometry905.597.7898

PATIENT INTAKE FORMPlease fill out the form belowAll field marked * are mandatory questions.

ADDRESS7181 Yonge Street, Unit 138Thornhill, ON L3T 0C7CONTACT

EyeWorld Optometry
905.597.7898

PATIENT INTAKE FORM
Please fill out the form below
All field marked * are mandatory questions.

ADDRESS
7181 Yonge Street, Unit 138
Thornhill, ON L3T 0C7

CONTACT