Last Name

First Name

Date of Birth (D/M/Y)

Health Card Number

Health Card Version Code

Address

City

Postal Code

Home Phone #

Cell Phone #

Email

Occupation

Date of Last Eye Exam

Location / Eye Doctor

Do you wear glasses? Yes No

If yes, please circle Distance Reading Both

Do you wear contact lenses? Yes No

If yes, what brand?

Have you ever had an eye or head injury? Yes No

If yes, please specify:

Have you ever had an eye infection? Yes No

If yes, please specify:

Have you ever had an eye surgery? Yes No

If yes, please specify:

Does anyone in your family (blook relatives) suffer from an eye disease? If yes, select and indicate relationship in space provided

Glaucoma Macular degeneration Eye turn Retinal Detachment Blindness Other

Are you currently suffering from any of the below conditions/diseases? (Please Check)

Diabetes High Blood Pressure High Cholesterol Heart Disease Thyroid Disease Macular Degeneration Cataracts Glaucoma

Are you pregnant or breastfeeding? Yes No Not Applicable

Family Doctor

Doctor's Phone Number

Are you allergic to any medication? Yes No

If yes, please specify:

NEW Patient Encounter Form

Contact Details

Working Hours

New Patient Form — Avalon Eye Care Vaughan

NEW Patient Encounter Form

Encounter Form Sent