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

Patient Information Update

Patient Full Name

Patient Date of Birth (mm/dd/yyyy - ex: 02/06/1999)

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Please update your street address, phone number, and email address

Street Address

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Phone

E-Mail Address

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Please indicate any changes to your overall health since your last visit (including pregnancy/nursing if applicable)

Please provide us with your family doctor’s name and location and an updated list of medications

Any medication allergies

Please provide us with your Vision Benefits Provider information

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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.