Patient Intake Form

Name: Sheridan Optometric Centre
Address: 103A-2155 Leanne Boulevard, Mississauga, ON, L5K 2K8, CA
Telephone: 905-822-3698
Price range: $000 - $300

Sheridan Optometric Centre

We welcome you to our practice and ask that you kindly complete information below:
Name:
First Last
Address:
Street Address Address Line 2 City Province Postal Code
Preferred daytime phone number:
Email address:
Date of Birth:
MM slash DD slash YYYY
OHIP #:
General Health & Ocular History
Current Medications:
Allergies:
Family Doctor & Contact Information
Please check off any current conditions that apply to you or your family members:
Self Family
Glaucoma
Cataracts
Diabetes
Retinal Detachement
Crossed/Lazy Eyes
Macular Degeneration
High Blood Pressure
Heart problems
Stroke
Thyroid Condition
Other
Glasses History
(skip if you don’t wear glasses)
What Glasses do you currently own?
How many hours a day do you use a computer?
How many inches (approx) do you sit from your computer monitor?
Contact Lens History
(skip if you don't wear contact lenses)
What brand of contact lens do you wear?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule?
Hours/day:
Days/week:
Please check off all that apply to you
- I am having problems with the vision out of my contact lenses
- I am having problems with the comfort of my contact lenses
- I am interested in refractive laser surgery
Occupation:
Hobbies:
Primary Insurance
Insurance Company Name:
Insured’s Name:
Identification number
Group Number:
Insured’s Date of Birth:
MM slash DD slash YYYY
Patient’s Relation to Insured
Secondary Insurance
(if applies)
Cancellation Policy
A 24 hour notice is required for all appointment cancellations. A cancellation fee of $25 will be charged for all missed appointments without 24 hour notice.

The information that I have given on this Intake Form is accurate and complete to the best of my ability. I understand that my information will remain confidential unless allowed or required by law.

When applicable, I acknowledge that I am responsible for the full cost of my appointment, payable at the same time as services are rendered.
Signature:
Date:
MM slash DD slash YYYY
Patient Privacy Protection
At Sheridan Optometric Centre, we responsibly uphold your right to privacy and respectfully request your consent to continue to stay in contact with you to remind you when it is time to review my eye and vision care needs and through our periodic email newsletters and promotions from Sheridan Optometric Centre.

In order to provide proper eye care and services, Sheridan Optometric centre will collect some personal information including your contact numbers, date of birth, address, OHIP number, medical conditions and medications. This information may be shared in the event that you are referred to another health care provider.

If you would like to provide consent to continue receiving reminder notices for your eye examinations and periodic informative email newsletters, please Sign below:
Signature:
Date:
MM slash DD slash YYYY

Attention OHIP patients, there are new changes starting September 1st.

Find out all the details here: http://www.ohipupdates.ca/

Patient Intake Form

Sheridan Optometric Centre

General Health & Ocular History

Glasses History

Contact Lens History

Primary Insurance

Cancellation Policy

Patient Privacy Protection

Follow Us

Office Hours

Patient Reviews

	Self	Family
Glaucoma
Cataracts
Diabetes
Retinal Detachement
Crossed/Lazy Eyes
Macular Degeneration
High Blood Pressure
Heart problems
Stroke
Thyroid Condition
Other