Patient Intake Form Patient Intake Form To ensure the best care and visual solution during your visit with us please fill out the form below. Name* First Last Phone number*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Date of Birth* How many years ago was your last full eye exam?*Have you ever had any eye injuries or surgeries?*YesNoPlease describe:Do you currently wear contact lenses?*YesNoWhich brand of contacts and solution do you use?How many hours per day do you use a computer or handheld device?*What is your occupation/job?What hobbies do you have?Who is your family doctor?Do you have: High Blood Pressure Diabetes Arthritis Please list all medication and vitamins that you currently take:*Please list any drug allergies that you have:*Do you have any family history of: Glaucoma Macular Degeneration Other Please describe:How did you hear about our office? Family/Friends Google search Phonebook/yellowpages Location Other Please tell us!