EYECARE

DR. SCIBERRAS

NEW
Mr. Mrs. First

PAT I E N T I N F O R M AT I O N
Ms. Dr. Last
Day

FORM

OPTOMETRIST
Name:

Date of birth (MM/DD/YYYY): Month OHIP #: Home Address: Home #: ( E-mail: Do you have school-aged children? Yes )

AGE: Version Code: Postal Code Contact #: ( Occupation: No If yes, age(s): ) (last 2 letters)

What type of corrective lenses do you use? Distance Glasses Contact Lenses Reason for Todays visit: Routine Check-up Sudden Vision Loss Need glasses Double vision Need contacts Flashing Lights / Floaters Irritated Eyes Headaches Reading Glasses None Bifocals Previous Laser Surgery Progressives (Invisible bifocals) Prescription Sunglasses

What year was your last eye exam? Do you have any of the following medical conditions: Glaucoma Thyroid Disease Current Medications: Family Doctor: Insurance Provider: How did you find out about our clinic: Internet Family/Friend Doctor Other Yes No Phone Book Hall Poster Phone # Vision Coverage: Yes No Amount: Cataracts Lupus High Blood Pressure Allergies Diabetes Other Arthritis

Do you plan on purchasing eyewear in the next three months?

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