Client InTake Form Partial InTake Page 1 CONTACT INFORMATIONThank 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 :Dr W ClarkeDr T MerwiakDr M ScottDr J LauDr J ZaguryDr K MacDiarmidDr K NorthDate of your appointment :Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay*12345678910111213141516171819202122232425262728293031Year*202020212022Name* First Last Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell PhoneWork PhoneEmail Address My preferred contact method is :*EmailCell PhoneHome PhoneWork PhoneDate of BirthMonth*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay*12345678910111213141516171819202122232425262728293031Year*2020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Health card number2 Letter Version CodeFamily Doctor NameFamily Doctor PhoneDo you have any particular concerns about your eyes or vision at this time?*YesNoPlease describe your concerns :PATIENT PRIVACY AND CONSENTWe 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. *