New Patient Intake Form

Name: Saugeen Shores Family Eye Care
Address: 643 Devonshire Road, Port Elgin, ON, N0H 2C3, CA
Telephone: (519) 832-5511

If you're new to our office, please fill out the form below so that we can get to know your ocular and medical history a bit better.
PERSONAL DEMOGRAPHICS
Legal Name*
First Last
Preferred Name (if different than above)
This is the name that you identify with. Providing this allows our team to address you appropriately.
Date of Birth*
MM slash DD slash YYYY
What are your preferred pronouns? (select all that apply)
- She/Her
- He/Him
- They/Them
Preferred Phone*
Type*
Secondary Phone
Type
This field is hidden when viewing the form
Type
- Home
- Cell
- Work
Email
Preferred Method of Communication*
This field is hidden when viewing the form
Preferred Method of Contact*
- Text
- Email
- Call
Address*
Street Address Address Line 2 City Province Postal Code
HEALTH CARD (OHIP) INFORMATION
We verify the eligibility of any OHIP eligible patients ahead of their appointments, if applicable.
10 Digit Number*
0 of 10 max characters
2 Letter Version Code*
0 of 2 max characters
Expiry Date*

Year
Month
Day
OCULAR HISTORY
Have you had any eye surgeries?*
- Yes
- No
If yes, please provide details:
Do you wear glasses?*
- Yes
- No
If yes, please choose all of the types:
- Distance
- Readers
- Bifocals
- Trifocals
- Progressives
- Sunglasses
Do you wear contact lenses?*
- Yes
- No
If yes, please elaborate:
- Full time
- Part time
- Interested in wearing
If yes, please let us know what brand of contacts you wear:

Are you currently experiencing any of the following problems with your eyes?*

MEDICAL HISTORY
Do you have any allergies?*
- No
- Yes, medication(s)
- Yes, environmental
- Yes, other
If yes, please provide details:
Do you take any prescription or non-prescription medicines?*
- Yes
- No
If yes, please list them or upload a copy of your med list below:
Please upload a copy of your med list, if applicable
Max. file size: 31 MB.

Please indicate if you or any of your blood-relatives have the following:*

PERSONAL DEMOGRAPHICS