Fill out the form before arrivingNew Patient InformationPrefer to print out the form and bring it in? Click here to download the PDF.Preferred Name*Email Address* Any personal history of...*GlaucomaCrossed/Lazy EyeMacular DegenerationRetinal DetachmentColour BlindnessBlindnessDiabetesHigh Blood PressureHeart ProblemsStrokeThyroid ConditionArthritisCataractsAny family history of...*GlaucomaCrossed/Lazy EyeMacular DegenerationRetinal DetachmentColour BlindnessBlindnessDiabetesHigh Blood PressureHeart ProblemsStrokeThyroid ConditionArthritisCataractsAre you interested in...*New GlassesA New PrescriptionLight Weight GlassesAnti-reflection CoatingDurabilityFashionContact LensesColoured Contact LensesSunglasses, Clip-onsSafety GlassesSport GlassesRefractive Surgery13141516How were you referred to us?*Family DoctorAnother PatientOtherMedications/supplements*Allergies*Occupation/School*Family Doctor*EmailThis field is for validation purposes and should be left unchanged.
