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Chorney Vision Centre Patient intake form
Welcome to Our office!

Please fill out for the form below to speed up your check in process.

Bring your insurance card and OHIP card to your appointment.
Email *
Title: *
Required
What is your name? *
When is your appointment with us? *
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I understand by not giving 24 hrs notice for cancellation, I am subject to a cancellation fee. *
Home Address with Postal Code *
Phone #: *
Date of Birth: *
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/
DD
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Vision Insurance Company:
Plan #:
Full name of Insured Person:
Health card # & version code (2 letters)
University Student ID#:
Family Dr: *
When did you last have an eye exam? (Approximately)
In accordance with the Privacy Act Jan. 1, 2004: I give Dr. David W. Chorney & associates permission to exchange my information with other health care providers or educators, when required for comprehensive care. *
Are you interested in LASIK eye surgery? *
Are you interested in trying contact lenses? Extra fees apply *
Have you worn contact lenses previously? *
Current Contact Lens Wearers
Do you nap or sleep in your contact lenses?
Clear selection
Do your contacts become less comfortable as the day progresses?
Clear selection
Are you interested in lenses which enhance or change your eye colour?
Clear selection
Type of lenses worn:
How many hours per day do you wear your contacts?
Type of cleaning solution used
Do you wear glasses? *
Age of present glasses:
Do you have a driver's license restriction? *
Do you spend time on a computer? *
Do you participate in any of the following activities? *
Required
Do you wear sunglasses for the above activities?
Clear selection
Has anyone in your immediate family been treated or diagnosed with any of the following conditions? *
Required
Have you been treated or diagnosed for any of the following conditions? *
Required
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