carousel_arrow cart circle_arrow circleCheck close-button contrast_arrow lightboxArrow pause-button pause play-2 play-button slideshow-arrow__large behance blogger dribbble dropbox facebook flickr github googleplus instagram lastfm linkedin paypal pinterest rss skype soundcloud spotify tumblr twitter vimeo youtube submitError svg-defsnull vector_arrow EYEWORLD OPTOMETRY905.597.7898 HomeAbout usEyecare ServicesEyecare ProductsBook an AppointmentChevronPATIENT INTAKE FORMOur LocationHomeAbout usEyecare ServicesEyecare ProductsBook an AppointmentChevronPATIENT INTAKE FORMOur Location PATIENT INTAKE FORMPlease fill out the form below First Name*Last Name*Date of Birth (MM-DD-YYYY)Phone Number*Email Address*Street Address*Province/State*Postal/Zip CodeWho is your family doctor?1. What is the reason for your visit?2. When was your last Eye Examination?3. Do you currently own prescription glasses?If yes, check all types of glasses you ownDistance onlyReading onlyProgressivesSafety glassesSports EyewearBackup GlassesComputer/Task GlassesPrescription SunglassesNon-prescription SunglassesAnti-fatique Glasses4. How many hours in a day are you looking at a screen? (Computer, mobile, etc)5. Have you had any previous eye health problem?6. Do you have any Medical Conditions?7. Please list any medication you are currently taking8. Are you currently under the care of a physician for any medical condition?9. Any family history of eye health problems?10. Any Family history of medical conditions?11. Do you have any environmental or medication allergies?12. What is your occupation?13. What hobbies do you enjoy?This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.SUBMITThank you! Your message was sent successfully. ADDRESS7181 Yonge Street, Unit 138Thornhill, ON L3T 0C7CONTACT P: (905)597-7898F: (905)597-7899 Email: [email protected] CLINIC HOURSMon 10:00 - 6:00Tues 10:00 - 7:00Wed 10:00 - 2:00 Thurs 10:00 - 7:00 Fri 10:00 - 6:00 Sat 11:00 - 5:00Sun Closed BOOK AN APPOINTMENT / PreviousNextPausePlayClose