Eye Doctor Fort
15 ROSSWELL DRIVE, UNITS 3 & 4 COURTICE, ONTARIO, L1E 0E2
Phone: (905) 571-7904 | email us
ORDER ONLINE! | Request Appointment | Office hours | Urgent eye care


New Patient Form
Title
Full Name
Date of Birth (M/D/Y)
Gender
Street Address
City
Prov
Postal Code
Home Phone
Cell Phone
Work Phone
E-Mail Address
Preferred method of contact
How Did You Hear About Us?
Health Card
Insurance Provider
Policy #
Group/Member #



OCULAR HISTORY

Do You Currently Wear Glasses?
Use Low Vision Aids?
Last Eye Exam
By Whom?

Patient and Family Ocular History

Please indicate if you or anyone in your immediate family (mother, father, siblings, children, and grandparents) have a history of any of the following, and please indicate the relationship to you, the patient.

Disease/Condition
Yes/No/?
Relationship
ARMD (Macular Degeneration)
Cataracts
Glaucoma
Keratoconus
Lazy Eye/Amblyopia
Retinal Detachment

Please Indicate If You Have Any History Of The Following

Eye Surgery
Eye Trauma
Eye Infections

Please Indicate If You Ever Had or Currently Have Any Of The Following

Floaters
Flashes of Light
Double Vision
Patching
Visual Training

Do You Wear Contact Lenses?
How Often Do You Wear Your Lenses/Hours Per Day?
How Often Are Lenses Disposed Of?
Sleep In Your Lenses?
If Yes, Number Of Nights Before Removal?
Brand of Lenses
Solution



MEDICAL HISTORY

Family Doctor/Location
Medications
Medication Allergies
Environmental Allergies
Patient and Family History

Please indicate if you or anyone in your immediate family (mother, father, siblings, children, and grandparents) have a history of any of the following, and please indicate the relationship to you, the patient.

Disease/Condition
Yes/No/?
Relationship
Asthma/Respiratory
Autoimmune Disease (e.g. Rheumatoid Arthritis)
Blood/Lymph
Cancer
Cardiovascular Disease
Depression
Diabetes
Gastrointestinal Disease
Hypertension
Kidney Disease
Multiple Sclerosis
Neuromuscular Disease
Skin
Stroke (CVA)
Thyroid
Other: Please Explain
Headaches
Women: Pregnant/Nursing?



SOCIAL HISTORY

Occupation
Computer Use/Hours Per Day
Hobbies/Sports You Participate In
Do You Smoke Cigarettes?
Are You An Ex-Smoker?
If Yes, For How Long?
What Year Did You Quit?



PATIENT INFORMATION CONSENT FORM

By signing below, you have agreed to give your informed consent to the collection, use and/or disclosure of your personal information for the following:
  1. To provide quality eye care in a safe and efficient manner
  2. To enable us to contact you and to maintain communication with you
  3. To allow us to contact you to book and confirm appointments
  4. To allow follow-up treatment, care, and billing
  5. To communicate with other health care providers when necessary
  6. To comply with legal and regulatory requirements
I give my informed consent to Avis Optometric Centre to collect, use and/or disclose my personal information for the purposes listed above.

Signature of patient / legal guardian (type your name)



Avis Optometric Centre's Eye Doctors and Staff Provide Quality Eye Care and Personalized Service You Can Trust!
Avis Optometric Centre 15 ROSSWELL DRIVE, UNITS 3 & 4 Courtice, ON L1E 0E2 Phone: (905) 571-7904 Fax: (905) 571-3045

Avis Optometric Centre proudly serves the Clarington and Durham Regions.

© 2022 All content is the property of Avis Optometric Centre ™ & assoc. vendors.
Website Powered and Developed by EyeVertise.com