Intake Form

Eye Exam $ 130. Eye Exam for Children 18 and under and Seniors 65 and Older -$30 (Balanced Billing with AB). If you have insurance, please present this with your from to predetermine your coverage

First Name*

Last Name*

Cell*

Email*

example@example.com

Address*

Postal Code*

GP NAME/MEDICAL CLINIC

Alberta Health Care*

Insurance Name

Policy Number

Group ID

Date Of Birth*

Date

I understand that I am responsible for all fees charged, and if Alberta Health Care rejects any claims I will pay the full amount. (Select Box) : Privacy*

I consent to the collection, use and disclosure of my/my dependent’s personal information as set out in the privacy statement.