EyeWorld Optometry



Please fill out the form below

All field marked * are mandatory questions.

Do you have an Ontario Health Card?*
Ontario Health Insurance number and version code
1. What is the reason(s) for your visit? Please select all that apply.*
If yes, check all types of glasses you own
3A. Do you wear specialty contact lenses such as Ortho-K lens or Dream lens?
6. Please check mark current medical conditions that apply to you:
Describe your current medical condition.
Skip if you don't wear contact lens
Skip if you don't wear contact lens
Skip if you don't wear contact lens
____________ Hours/Day, __________Days/Week (Skip if don't wear contact lenses)
18. Please checkmark if it applies to you:
Skip if you don't wear contact lenses
A 24 hour notice is required for all appointment cancellations. A cancellation fee will be charged for all missed appointments without 24 hour notice. The information that I have given on this Intake Form is accurate and complete to the best of my ability. I understand that my information will remain confidential unless allowed or required by law. When applicable, I acknowledge that I am responsible for the full cost of my appointment, payable at the same time as services are rendered. Do you agree to the Cancellation Policy Agreement?*
At EyeWorld Optometry, we responsibly uphold your right to privacy and respectfully request your consent to continue to stay in contact with you to remind you when it is time to review your eye and vision care needs and through our periodic email and text messages from EyeWorld Optometry. In order to provide proper eye care and services, EyeWorld Optometry will collect some personal information including your contact numbers, date of birth, address, OHIP number, medical conditions and medications. This information may be shared in the event that you are referred to another health care provider. Do you agree to this Patient Privacy Protection agreement? *
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