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COVID Arrival Form and Consent

  • By signing this form, you consent to Freelton Eye Care’s collection of the information above and share your personal information ONLY 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.

    We will take ALL possible steps to ensure that your personal information is treated confidentially and to prevent unauthorized access, use or disclosure of your personal information.

    • Accepting payment receipts and glasses prescriptions via email when applicable
    • Providing my personal health information to ensure the time I spend in the officeis efficient and focused on my medical care.
    • Application of a $100 charge on the officially-booked appointment date if I do notattend my appointment OR cancel with fewer than 2 business days’ notice.

  • Date Format: MM slash DD slash YYYY

Revised Handout 2021 03 30(1) page 001