WELCOME TO OUR OFFICE

Date

Day

Month

Year

Patient Name *

First

Last

DOB (M/D/Y) *

Day

Month

Year

Address *

Street Address

City

State

Zip

Phone: Home

Work

Cell

Occupation

E-mail

Date of Last Eye Exam

Day

Month

Year

Alberta Health Care #

Family Doctor

Doctor Phone

Location

How did you hear about us?

What is the main purpose of this eye exam?

Do you wear contact lenses?

No

Yes

Interested in contact lenses?

Brand name of contact lenses

How many hours per day

Others (Ocular History)

Do you have any known allergies including drug allergies?

YES

NO

If yes, please list:

Current medications (including eye medication): please list or circle “NONE”

I, the undersigned, confirm that the information given in this medical history is complete and true to the best of my knowledge. I authorize the use of topical anaesthetics, medications and delivery of treatment once agreed upon by myself (parent/guardian) and the doctor. I also agree that I (parent/guardian) am ultimately responsible for all fees/charges incurred for my eye care in this office, not provided for by any government insurance program.

Signature of patient (Parent/Guardian of a minor)

Signature Date

Day

Month

Year