Dr.Oliphant Pre-test Form

Telephone : (519) 354-5870

Take your pre-test now

Pre-test

Dr. Oliphant has found that many new patients prefer to provide basic information through this online feature before their first visit. This allows staff to create your personal eye care file before you arrive and shortens your initial visit. Of course, all information is secure and held in the strictest of confidence. One more reason to make Dr. David Oliphant, your eye care specialist.

Name
Title
Street address
City/Town
Postal code
Residence phone
Business phone
Cellular phone
Where do we call you
When should we call you
E-mail address
Date of birth
Occupation
Do you currently wear glasses	Yes No
Do you currently wear contact lenses	Yes No
Do you wear sunglasses
OHIP number
Your medical history	High Blood Pressure Diabetes Heart disease Thyroid disorder Lazy/Crossed Eye Eye injury / Infection Glaucoma Other
Your family history	Glaucoma Cataracts Lazy/Crossed Eye Other
Current medication being taken (Including over the counter)	Blood pressure Heart Eye Drops Diabetic Other
Third party insurance