Client InTake Form - InTake OHIP Mandatory

Step 1 of 5

CONTACT INFORMATION
Thank you for taking 4-5 minutes to ensure we have the most up to date information on your file in our office. Collecting and confirming this information in advance will help minimize your time in office and improve office safety measures.
Name of your doctor :
Date of your appointment :
Month*
Day*
Year*
Name*
First Last
Address
Street Address City Province Postal Code
Home Phone
Cell Phone
Work Phone
Email Address
My preferred contact method is :*
Date of Birth
Month*
Day*
Year*
Health card number*
2 Letter Version Code*
Family Doctor Name
Family Doctor Phone
Do you have any particular concerns about your eyes or vision at this time?*
- Yes
- No
Please describe your concerns :

OHIP

Thanks to the support and advocacy of our incredible patients, we are happy to announce that the Ontario Optometrists job action is on pause effective November 23rd 2021.

The Ontario Association of Optometrists has entered into negotiations with the provincial government.

If you are an OHIP insured patient, please do not call to book or rebook your appointment.

We will reach out to OHIP patients whose appointments were cancelled or rescheduled due to job action.

We must once again ask for your patience, as we have had over 2000 cancellations and are taking care to make sure that the patients with time-sensitive eye conditions are placed in priority order.

We are mobilizing the team of staff and doctors to schedule additional catch-up clinics and we will work our way through the list beginning today.

Please do not book your appointment online as you may not be booking the necessary testing. Please wait for a member of our team to contact you.

We are grateful to be welcoming our seniors and children back. Thank you for your kindness, support and understanding during these turbulent times for optometry in Ontario. Click here to learn more.

The Teams at Merivale & Wellington Vision Care

Client InTake Form - InTake OHIP Mandatory

Step 1 of 5

CONTACT INFORMATION

EYE / VISION HISTORY

MEDICAL

CORRECTIVE LENS INFORMATION

CONTACT LENSES

VISUAL NEEDS

PATIENT PRIVACY AND CONSENT