New Patient Information FormPlease fill out the form below prior to your appointment. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY OHIP Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of last eye exam If applicable MM DD YYYY Occupation/Hobbies Family Physician * Eye History Do you have any of the following: Glaucoma Macular degeneration Cataract Lazy eye/turned eye Eye injury/Surgery Retinal detachment Colour vision defects General Health History Do you have any of the following: Diabetes High blood pressure Heart disease Blood disorder Thyroid condition Arthritis Other Please list any conditions you have that were not listed above: Family History Please list any family members that have been diagnosed with any of the above eye or general health conditions. Please list any current medications: Please list any allergies: Do you wear glasses? * Distance Reading Progressive/Bifocal No Do you wear contact lenses? * Yes No What is the reason for your visit? Please include any other information you would like us to know. Thank you!
