BWO Adult Intake Form

Please complete the information below. This form contains confidential information and is delivered to your doctor through a secure internet delivery system.

BWO Adult Intake Form

Full Name
Invalid Input

DOB

Invalid Input

Primary Phone Number
Invalid Input

Email Address(*)
Invalid Input

Invalid Input

Family Doctor’s Name
Invalid Input

Family Doctor’s Phone Number
Invalid Input

Last Complete Medical Exam

Invalid Input

Private Health Insurance Information:
Insurance Company
Invalid Input

Name of Policy Holder
Invalid Input

Policy
Invalid Input

Member ID
Invalid Input

Do you have dependent coverage Y / N
Invalid Input

Main reason for today’s visit
Invalid Input

Do you wear glasses or sunglasses? If so, describe what you use them for
Invalid Input

Do you wear contact lenses? If so, list brand, power (if known) and wear schedule
Invalid Input

Are you interested in
Invalid Input

Please list any chronic health conditions
Invalid Input

Please list any medications you are currently taking
Invalid Input

Please list any eyedrops you are currently using
Invalid Input

Please list any allergies to medications or other
Invalid Input

If you have any blood relatives with eye diseases, please list the conditions and relations here
Invalid Input

Please indicate type and date of any recent eye surgery or eye injuries
Invalid Input

Do you see any other eye care practitioners? If so, list the date and reason forthe last visit
Invalid Input

NOTICE OF COLLECTION OF PERSONAL INFORMATION AND CONSENT TO COLLECT READ CAREFULLY BEFORE SIGNING:
By signing this form, you consent to our collection of the information above. Our office collects, uses and shares your personal information for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibility 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 Health Protection and Promotion Act. Our office will take all reasonable steps to ensure that your personal information 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 the address in the email footer.
More information about our collection, handling and protection of personal information is available in our privacy policy. Please contact our office to request a copy of the policy.
If you would like to make a comment or complaint regarding the collection, use, disclosure or handling of your personal information you may contact our office by email, fax, or phone. 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)
I,
Invalid Input

have read the information on this form andconsent to the above.
Date

Invalid Input

By typing my name, I agree to the terms listed above.