Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Email Address*

Please provide us your email address.

Communication Preference*

Personal Information

Gender*

Female
Male

Date of Birth*

Saskatchewan Health Card Number

Please enter a number from 0000 to 9999.

Occupation

How did you hear about our office?

Eye History

Please check concerns

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Single Vision
Bifocal
Trifocal
Progressive
Office Glasses
Sunglasses
Safety Glasses
Sunglasses
Other

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

Any problems with your current glasses?

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was the last time you saw your family doctor?

Who is your family doctor?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list any allergies you may have.

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

If you have any comments you would like to add, please enter them here.

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Email

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