InSight Optometry Patient Intake Form WELCOME TO OUR CLINIC! INSIGHT OPTOMETRY PATIENT INTAKE FORM To better assist you, we would ask that you kindly fill out this form. Full Name* First Last Preferred Name: Name Guardian/Parent of Child:* Relationship to the patient:* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Date of Birth (MM/DD/YY)* MM slash DD slash YYYY Email* Phone number** Home Cell Occupation* Family Doctor* PHN # (Care Card):* Preferred Method of Contact:* Email Phone Text May we contact you with the following information:* Appointment Reminders Order updates InformatIon about sales and promotions Newsletters I don't wish to be notified Are you planning on using extended benefits for any portion of your visit?* Yes No If yes, please provide policy details or a picture of your benefits card Policy Details or Upload a picture of your benefits card hereMax. file size: 128 MB.Reason for eye exam:* RoutIne Eye Exam Trouble with vision Eye Health concern AdditIonal informatIon (optIonal):When was your last eye exam?* Name of the Clinic* Do you wear:* PrescriptIon glasses Contact Lenses History of CorrectIve Surgery Current glasses:* Working well Needs Adjusting/Cleaning Broken/Lost Needs updating Contact lenses:* Working well Need new supply Not comfortable Needs updating Your Medical HistoryEyes Glaucoma Cataracts Macular degeneration Dry Eyes Blepharitis Lazy Eye Retinal holes/detachments Blindness General Health Cancer High blood pressure Diabetes Cholesterol Heart Problems Stroke Thyroid Asthma Other: Family Medical HistoryEyes Select All Glaucoma Cataracts Macular degeneration Dry Eyes Blepharitis Lazy Eye Retinal holes/detachments Blindness General Health Cancer High blood pressure Diabetes Cholesterol Heart Problems Stroke Thyroid Asthma Other: Allergies: Medications:Is there anything else you would like the doctor to know about your visit:How did you hear about InSight Optometry* Another patient Website/Google Social Media Referral from another doctor/professional: PhoneThis field is for validation purposes and should be left unchanged.