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Patient Information Form
Thank you for taking the time to fill out this form. Please note that completing this Intake Form DOES NOT guarantee an eye appointment. We are currently triaging a backlog of patients. If you feel you need an urgent appointment or don't hear from us within a week, you may call another eye care professional or go to the nearest hospital. Thank you.
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Last Name, First Name
*
Your answer
Address
*
Your answer
City
*
Your answer
Postal Code
*
Your answer
Cell Number
Your answer
Home Number
*
Your answer
Email Address
*
Your answer
OHIP card & Version Code--While providing a health card is optional for private-pay services, please be advised that a $50 administrative fee applies if an exam converts to OHIP coverage and a physical, valid health card is not presented at the time of service.
*
Your answer
Date of Birth (YYYY/MM/DD)
*
Your answer
Occupation
Retired
Student
Other:
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Hobbies (eg. reading, computers/tablet, sewing)
Your answer
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