OHIP covers the BASIC elements of an eye examination. Freelton Eye Care uses advanced diagnostic testing NOT covered by OHIP to detect and manage eye disease earlier and more precisely, resulting in better health outcomes. These diagnostic services include Visual Field Screening & Analysis; Optical Coherence Tomography (OCT-Disc and/or Macula) & Analysis; and Baseline Fundus Photography. I hereby consent to:

Providing my credit card information to enable Freelton Eye Care to set up contactless payment and hold my spot scheduled for the services outlined above. (providing Credit Card essential at the time of booking or at the time of returning this consent form)
Accepting payment receipts and glasses prescriptions via email.
Requesting re-issue of prescriptions at a charge (original issue always included with eye exam)
Application of a $100 charge on the officially-booked appointment date if I do not attend my appointment OR cancel with fewer than 48 hours’ notice.

Preferred Method of Payment (for services rendered on the day of visit)
***Please note Debit and E-Transfer is not sufficient to hold your appointment spot***

CREDIT CARD
DEBIT
E-TRANSFER (Must be set up with online banking through any financial institution and send payment to freeltoneyecare@gmail.com)

Consent*

I consent to Freelton Eye Care’s collection of the information above

By signing this form, you consent to Freelton Eye Care’s collection of the information above. We collect, use and share 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 in accordance with the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Health Protection and Promotion Act.

We 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.

I have read the information on this form and DO CONSENT to the above.

Name*

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Signature*

Date*

Consent to Fee Collection

Consent to Fee Collection Form

Freelton Eye Care