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

Patient Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City Province Postal Code

Phone Number*

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

Email Address*

Please provide us your email address.

Family Doctor/clinic:

Alberta Health Care #:

New patient only - How did you find us?

Occupation:

Last Eye Exam:*

Vision/Ocular History & Concerns:

Other

Dry Eye Symptoms:

Contact Lenses:

Renew Prescription
First time Wearer
Bifocal Contact lenses
Coloured Contact Lenses

Medical History:

Other

Do you Smoke?*

Yes
No

Are you Pregnant?*

Yes
No

Medications:*

Allergies:*

Surgeries:*

Primary Insurance

Insurance Company Name

Insured Name (as on Card)

First Last

Insured Date of Birth

Patient Relation to Insured

Group Number

Policy Number

Secondary Insurance

Do you have secondary insurance?

Yes
No

Insurance Company Name

Insured Name (as on card)

First Last

Insured Date of Birth

Patient Relation to Insured

Policy Number

Group Number

Comments

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Email

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