Child’s Family Doctor’s Name
Child’s Family Doctor’s Phone Number
Last Complete Medical Exam
Private Health Insurance Information:
Main reason for today’s visit
Does your child wear glasses? If so, describe how often and what they use them for
Does your child patch one eye or do vision training exercises? If so, describe type and frequency
Does your child wear contact lenses? If so, list brand, power (if known) and wear schedule
Does your child wear sunglasses?
How many hours does your child spend on computers and/or devices?
Is your child struggling academically or experiencing behavioural problems at school? If so, please describe
Please list any chronic health conditions
Please list any medications your child is currently taking
Please list any eyedrops your child is currently using
Please list any allergies to medications or other
Does your child have any immediate blood relatives with eye diseases? If so, please list the conditions and relations here
Has your child had any recent eye surgeries or injuries? If so, please indicate type and date
Does your child see any other eye care practitioners? If so, list the date and reason for the last visit
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.
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, (parent/guardian name)
have read the information
andconsent to the above as parent /guardian of (child’s name)
By typing my name, I agree to the terms listed above on behalf of my child