Patient Intake Form Patient Intake Form Please enable JavaScript in your browser to complete this form.1Information2Extended Health3Health Concerns4ContactPatient InformationName on care card (Last, First) *Date of Birth (MM/DD/YY) *PHN (Care Card Number) *Address *City *Postal Code *Gender *Occupation *Last Eye Exam *Family Doctor *Referred From *Reason For Visit *NextExtended HealthDo you have extended health? *YesNoInsurance Company *Insured Member Name (Last, First) *Patient Relationship to Insured Member *Policy Number *Member ID *Do you have secondary coverage? *YesNoInsurance Company *Insured Member Name (Last, First) *Patient Relationship to Insured Member *Policy Number *Member ID *PreviousNextHealth ConcernsComputer Usage (hrs/day) *Contact Lens Wear (hrs/day) *Medical History *HypertensionDiabetesNoneOthers:Medical History (Others) *Allergies *Medications *Ocular History *GlaucomaMacular Degeneration CataractsNoneOthers:Ocular History (Others) *PreviousNextContact InformationEmail *Home Phone *Mobile Phone *Appointment Reminder PreferenceI would like to receive appointment reminders by emailI would like to receive appointment reminders by text Cancellation Policy Cancellation of appointment requires a minimum of 24 hour notice. A $50 cancellation or no-show fee will be required if appointment is cancelled within the 24 hour window. PreviousSubmit
