Website www.icareoptometry.ca Email info@icareoptometry.ca Phone 416.526.2020 Fax 437.836.4404 Address 1450 Midland Ave, Suite# 207Scarborough ON M1P 4Z8 Social Media Facebook Instagram LinkedIn HOURS OF OPERATION Monday – Thursday 10 AM-6 PMFriday : 2 PM – 7 PMSaturday : 9 AM – 2 PMSunday : Closed Book Appointment New Patient Registration Form New Patient Registration FormPlease fill out as much information as possible: Patient History FormPATIENT INFORMATIONFirst NameLast NameDate of BirthAgeAddressAddress Line 1CityPostal CodePhoneEmailWorkHealth Card #V.C.ExpiryOccupationMEDICAL / EYE HISTORY (✓ all that apply) Painful eyes Blurred vision Vision loss Headaches Red eyes Dry eyes Sensitivity to light Eye infection Eye injury Double vision Crossed eye Lazy eye Cataracts Glaucoma Diabetes High blood pressure Heart condition Thyroid condition Eye medicationsMEDICATIONS1.2.3.ALLERGIES1.2.3.REASON FOR TODAY’S VISIT:VISION CONCERNSDifficulty seeing: Far Near Computer NightVision history: Glasses Contact lenses Eye patchSURGERY / HOSPITALIZATIONHave you ever had surgery (if yes, explain):Have you been hospitalized in past year? Yes Noif yes please explainREFERRALHow did you hear about us?SIGNATUREDate (MM/DD/YYYY):Submit Form
