Adult Patient Intake Form 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. *Fields marked with an asterisk are required and must be completed before submitting. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Date* MM slash DD slash YYYY Patient InformationFull Legal Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Preferred Name* Assigned Sex at Birth Pronouns Emergency Contact* Contact's Phone #*Patient Email Address* May we contact you via email?* Yes No May we contact you via text?* Yes No How did you hear about our clinic?* Website/Google/Yellow page/Referral (name)Personal InformationDate of Birth (mm/dd/yyyy)* Occupation* Hobbies* (certain hobbies have unique visual demands)Family Doctor* Date of last medical exam.* Medications*(please provide a list to be scanned if possible)Allergies*(please include drug and environmental)Are you or could you be pregnant/nursing?* Yes No If pregnant, how many weeks? Are you or were you ever a smoker?*>Select>YesNoQuitWhen did you quit? Reason for seeking an eye examination today.* When was your last eye exam?*>Select>1 year2 years3-5 years5-10 year10+ yearsNeverGlasses & Contacts HistoryDo you presently wear glasses?* Yes No List what type/s Do you presently wear contact lenses?* Yes No What brand and type Eye HistoryAre you currently under the care of an ophthalmologist?* Yes No Please provide the name Have you ever been diagnosed with an eye disease?* Yes No Please list Have you ever had surgery on your eyes?* Yes No Please provide details and dates Have you ever had any injuries to your eyes?* Yes No Please provide details and dates Are you interested in wearing contact lenses?*>Select>YesNoDo you have a driver's license?* Yes No What class license do you have? Are you required to wear corrective lenses (glasses or contacts) while driving?* Yes No Personal and Family Ocular and General Health HistoryGlaucoma* No Self Family Family (list relationship) Cataracts* No Self Family Family (list relationship) Macular Degeneration* No Self Family Family (list relationship) Strabismus ("turned eye")* No Self Family Family (list relationship) Amblyopia ("lazy eye")* No Self Family Family (list relationship) Other eye diseases (Retinal Detachment)* No Self Family Family (list relationship) Diabetes* No Self Family Family (list relationship) High Blood Pressure* No Self Family Family (list relationship) Thyroid Disease* No Self Family Family (list relationship) Arthritis* No Self Family Family (list relationship) Insurance ProviderPlease bring all insurance cards with you to your appointment.Insurance Provider: (ie Great West Life, Manulife)* Missed Appointments and Cancellation PolicyScheduled Appointments* I have read and agree to the below policy.At St. Lawrence Optometry, we strive to provide excellence in patient-centered eye care and ocular health. Part of that service may mean you are called back for follow-up appointments, most of which we make at the end of your initial visit with us. If for some reason you are unable to make a booked appointment, whether for a full exam or follow up, we ask that you notify us by phone/email/in person 24 hours in advance of your scheduled appointment time. This policy is in place given the limited availability of appointment spots. Please note that there is a $60 missed appointment fee for those that do not comply with this cancellation policy. I certify that I have been made aware of this policy and agree to maintain my scheduled appointments to the best of my ability. I understand that in certain instances, I may be charged the $60 missed appointment fee if I fail to give 24 hour notice of missing my appointment.CommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy CommentsThis field is for validation purposes and should be left unchanged.
Please call our clinic to confirm operating hours as they are subject to change without notice.