Client InTake Form Partial InTake Page 1

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 :
PATIENT PRIVACY AND CONSENT
We are committed to protecting the privacy of our patients’ personal information and to utilizing all information in a responsible and professional manner. Our purposes for collecting, using and disclosing your personal information will be limited to those which are related to providing you with clinical care and optical products and services. This may include using such information to send you recalls and appointment reminders. Personal information will only be shared when clinically necessary for referrals and ongoing care. Merivale Vision Care and Wellington Vision Care are separate but integrated clinics. Our doctors work in both offices and will view your information at the location you are being seen.
Consent
I hereby consent to the collection, use and disclosure of my personal information as set out above. *

Client InTake Form Partial InTake Page 1

CONTACT INFORMATION

PATIENT PRIVACY AND CONSENT