Patient_Form old version

First Name *

Last Name *

Cell *

Email *

Address

City

Province

Postal Code

Insurance Name/Policy Number/Group ID

Alberta Health Care

Date Of Birth:

Date

Occupation

Hobbies

Emergency Contact/Relationship

Emergency Contact Telephone

How did you hear about us?

Do you wear CL/Glasses/Both (Please Circle)

CL Glasses Both

Would you be interested in trying Contact Lenses?

Yes No Both

If you wear contact lenses, state the name or brand

Last Eye Exam

Allergies

Medications

General Health/Health Concerns

Vision Concerns

Past Vision Concerns/Surgeries

Family Medical History:

Family Vision History:

I understand that I am responsible for all fees charged, and if Alberta Health Care rejects any claims I will pay the full amount. *

I consent to the collection, use and disclosure of my/my dependent’s personal information as set out in the privacy

Patient Name: _____________________ Parent and or Guardian: