BWO Adult Intake Form

Full Name
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DOB

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Primary Phone Number
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Email Address(*)
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Family Doctor’s Name
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Family Doctor’s Phone Number
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Last Complete Medical Exam

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Private Health Insurance Information:
Insurance Company
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Name of Policy Holder
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Policy
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Member ID
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Do you have dependent coverage Y / N
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Main reason for today’s visit
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Do you wear glasses or sunglasses? If so, describe what you use them for
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Do you wear contact lenses? If so, list brand, power (if known) and wear schedule
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Are you interested in
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Please list any chronic health conditions
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Please list any medications you are currently taking
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Please list any eyedrops you are currently using
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Please list any allergies to medications or other
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If you have any blood relatives with eye diseases, please list the conditions and relations here
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Please indicate type and date of any recent eye surgery or eye injuries
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Do you see any other eye care practitioners? If so, list the date and reason forthe last visit
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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,
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have read the information on this form andconsent to the above.
Date

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