NEW Patient Encounter Form

If you are a new patient please fill out and submit questionaire prior to coming to your appointment.



Do you wear glasses?
If yes, please circle            

Do you wear contact lenses?
If yes, what brand?

Have you ever had an eye or head injury?
If yes, please specify:

Have you ever had an eye infection?
If yes, please specify:

Have you ever had an eye surgery?
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


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


Are you pregnant or breastfeeding?


Are you allergic to any medication?
If yes, please specify:

Schedule your eye exam by calling 905-856-EYES (3937) or using our online booking tool