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...* Glaucoma Crossed/Lazy Eye Macular Degeneration Retinal Detachment Colour Blindness Blindness Diabetes High Blood Pressure Heart Problems Stroke Thyroid Condition Arthritis Cataracts None OtherAny family history of...* Glaucoma Crossed/Lazy Eye Macular Degeneration Retinal Detachment Colour Blindness Blindness Diabetes High Blood Pressure Heart Problems Stroke Thyroid Condition Arthritis Cataracts None OtherPersonal History - Other:Family History - Other:Are 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*Upload Medication FileAccepted file types: jpg, gif, png, pdf, pages, excel, keynote.Allergies*Occupation/School*Family Doctor*What is the primary reason for your visit?Family Doctor*Do you wear contact lenses? Yes No I used to wear contacts, but stoppedPhoneThis field is for validation purposes and should be left unchanged.
