• 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

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  • Patient Information

    Please complete the following personal information
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  • Billing & Insurance Information

  • Personal Medical History

  • COVID-19 Health History

  • Purpose of Your Visit

  • Current Glasses

    Please bring your current glasses & sunglasses to your exam

  • Should be Empty: