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Home » Patient Intake Form

Patient Intake Form

Sheridan Optometric Centre

  • We welcome you to our practice and ask that you kindly complete information below:
  • MM slash DD slash YYYY
  • General Health & Ocular History

  • SelfFamily
    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)
  • Contact Lens History

    (skip if you don't wear contact lenses)
  • What is your typical wearing schedule?
  • Primary Insurance

  • MM slash DD slash YYYY
  • (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.
  • 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:
  • MM slash DD slash YYYY