Assessment Request Form

Request a Complimentary Eye and Vision Assessment

After you submit this form, a Patient Counselor will contact you to book an appointment for your assessment.

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Salutation

First Name

Last Name

Birthdate

Address

City

Province/State

Country

Postal/Zip

Fax

Telephone (H)

Telephone (W)

Telephone (C)

Contact me at

Home

Work

Cell

Best Time(s)

Who is your ophthalmologist?

Who is your optometrist?

What do you do for a living?

Hobbies

Has your eye sight been generally stable for the last year?

Current Eyeglass or Contacts Prescription

Left

Right

Do you wear contacts?

If you are a contact lens wearer, what type do you wear?

If you answer "YES" to any of these questions, please give us DETAILS in the space provided (if "No" leave blank)

Do you have health problems with your eyes, have you had a previous eye injury, or have you been diagnosed with an eye disease?

If Yes Please Specify

Have you had previous eye surgery?

If Yes Please Specify

Do you have any health problems?

If Yes Please Specify

Are you on any medication?

If Yes Please Specify

Do you have any allergies to medication?

If Yes Please Specify

Are you pregnant or nursing, or do you plan to get pregnant within the next year?

If Yes Please Specify

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