Excellence in Eye Care

Patient Information Form

Preferred Title

Gender

Were you referred for examination by:
Did you hear about us through:

Case History

Do you wear Spectacles or Contact Lenses?

Have you ever had an EYE INJURY, EYE INFECTION that needed treatment or EYE SURGERY?

Are you ALLERGIC to anything? This also includes MEDICINES:

At times, the optometrist may deem it necessary to refer you to another health professional. A referral will only occur with your permission.

I agree to allow relevant medical and visual history to be provided to the other health professional when required.


  • We recommend that you have a routine comprehensive eye examination every two years to ensure your eye health and that any necessary optical correction is updated or provided for your daily needs.  Request an appointment for an comprehensive eye examination today!
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