Intake Form

Intake Form

Pre-examination form with medical history and appointment needs
Due to COVID-19, our office procedures have been enhanced for your safety. To ensure a safe and efficient visit for you, we require that you complete and submit this Medical History and Needs Form in the next 48 hours to guarantee your appointment.
Notice of Collection of Personal Information

READ CAREFULLY BEFORE SIGNING
"We" and "our" mean Spadina Optometry.

We collect, use and share your personal infomation for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibiltiy for benefits and/or services; to arrange payment for services; and as required by law.

The collection of this information is authorized by the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Healh Protection and Promotion Act.

We will take all reasonable steps to ensure that your personal infomration is treated confidentially and is only used for the purposes it was collected. We will take all reasonable steps to prevent unauthorized access, use or disclosure of your personal information.

You may obtain access to your personal information stored by us in accordance with the Personal Health Information Protection Act by making a written request to: Privacy Officer, Spadina Optometry, 127 Spadina Ave, Toronto, ON M5V 2K8

More information about our collection, handling and protection of personal information is available in our privacy policy, posted online at https://spadinaoptometry.ca/privacy-policy/

If you would like to make a complain regarding the collection, use, disclosure or handling of your personal information you may contact: privacy@spadinaoptometry.ca

You also have the right to complain to the Information Privacy Commissioner / Ontario, 1400-2 Bloor Street East, Toronto, ON M4W 1A8 (800)-387-0073
Name *

First Name Last Name
I have read the information and DO consent to the above. *

I consent to the collection of my personal information for the purposes described above.
Signature *

Clear
Date *

Month Day Year
Date Hour Minutes AM/PM Option

Patient Information

Please complete the following personal information
Name

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Primary Phone *

Area Code Phone Number
Secondary Phone

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred Method of Contact *

Email Phone Text
Billing & Insurance Information
Health Card Number & Version Code
Expiry Date
Do you have third-party insurance?

Yes No I am unaware of my insurance information
Plan Name
Policy #
Group #

Personal Medical History
Please list any medical conditions
Have you been diagnosed with an eye disease?
Please list any previous eye surgeries
Please list any medications you are currently taking
Please list any allergies
Please list any eye diseases that run in your family

Intake Form

Notice of Collection of Personal Information

Patient Information

Billing & Insurance Information

Personal Medical History

COVID-19 Health History

Purpose of Your Visit

Current Glasses