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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.

do or do not , there is no try check that box

Salutation

First Name

Last Name

Birthdate

Address

City

Province/State

Postal/Zip

Telephone

Has your eyesight been generally stable for the last year?

Who is your ophthalmologist?

Who is your optometrist?

Your occupation or type of work:

Your hobbies:

Current Eyeglass or Contact Lense Prescription

Right eye OD:

Left eye OS:

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.

Do you have any 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

As a child, did you have to wear a patch on one eye?

If Yes Please Specify

Have you had previous eye surgery?

If Yes Please Specify

Do you have any health problems? (i.e., Diabetes, Collagen disease, Autoimmune disease such as Rheumatoid Arthritis or Lupus)

If Yes Please Specify

Do you take any medication?

If YES, please list medications currently used: Include ImitreX (migraine), Amiodarone (cardiac anti-arrhythmic), Flomax (urinary flow), and Accutane (aka Epuris for acne). If Accutane used, must be discontinue for at least 6 months.

Do you have any allergies to medication?

If Yes Please Specify

Do you have any allergies to nuts or shellfish?

If Yes Please Specify

Do you have any allergies to surgical tape, iodine or latex gloves?

If Yes Please Specify

If you are allergic to latex, is your allergy airborne or contact?

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

If Yes Please Specify

Have you undergone a refractive assessment elsewhere?

If yes, were any concerns or conditions identified that may necessitate special testing or attention?

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