Fill out the form before arriving New Patient Information Prefer to print out the form and bring it in? Click here to download the PDF. "*" indicates required fields Full Name* First Last Email Occupation/School* Family Doctor* First Last Current Medications/supplements*Upload Medication FileAccepted file types: jpg, gif, png, pdf, pages, excel, keynote, Max. file size: 128 MB.Allergies* What is the primary reason for your visit? Do you wear contact lenses? Yes No I used to wear contacts, but stopped I am interested in trying them Do you currently use any eye drops? Yes No Which ones Do you have any symptoms of dry eyes? These include grittiness, stinging, burning, redness and excessive watering with prolonged screen time. Yes No Any personal history of...* Glaucoma Crossed/Lazy Eye Macular Degeneration Retinal Detachment Colour Blindness Blindness Diabetes High Blood Pressure Heart Problems Stroke Thyroid Condition Arthritis Cataracts None Other Any family history of...* Glaucoma Crossed/Lazy Eye Macular Degeneration Retinal Detachment Colour Blindness Blindness Diabetes High Blood Pressure Heart Problems Stroke Thyroid Condition Arthritis Cataracts None Other Personal History - Other: Family History - Other: How were you referred to us?*Family DoctorAnother PatientOnlineOtherEmailThis field is for validation purposes and should be left unchanged.
