15 ROSSWELL DRIVE, UNITS 3 & 4 COURTICE, ONTARIO, L1E 0E2
Phone: (905) 571-7904 | email us
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Consultation Request

Dilated Fundus Examination

New Patient Form

Patient Information Update

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:

To provide quality eye care in a safe and efficient manner
To enable us to contact you and to maintain communication with you
To allow us to contact you to book and confirm appointments
To allow follow-up treatment, care, and billing
To communicate with other health care providers when necessary
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.