Your Name (Required)

Title
 Mr Mrs Miss Ms

Street Address

City/Town

Postal Code

Residence Phone

Business Phone

Cell Phone

Where do we call you?

When should we call you?

Email Address (Required)

Date of Birth (MM-DD-YY)

Occupation

Do you currently wear glasses?

Do you currently wear contact lenses?
 Yes No

Do you wear sunglasses?

Amount of computer use per day in hours

Amount of smart phone or tablet use per day in hours

OHIP Number

Your Medical History
 High blood pressure Diabetes Heart disease Thyroid disorder Lazy/crossed eye Eye injury/infection Glaucoma

Other medical history

Your Family History
 Glaucoma Cataracts Lazy/crossed eye

Other family history

Current medication being taken (Including over the counter)
 Blood pressure Heart Eye drops Diabetic

Other medications

Third Party Insurance