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Medical History

Medical History and Needs Form

  • Due to COVID-19, to ensure a safe and efficient visit with Freelton Eye Care, we ask that you complete and submit this form within 2 business days to guarantee your appointment.

    *If a question does not apply to you or you are unsure of the answer, indicate “N/A” or “unsure”; DO NOT LEAVE BLANK!
  • 1. PATIENT INFORMATION

  • MM slash DD slash YYYY
  • *For questions regarding anti-spam legislation, go to crtc.gc.ca/eng/com500/faq500.htm
  • OHIP:
  • MM slash DD slash YYYY

  • 2. MEDICAL HISTORY and VISUAL NEEDS


  • COVID-19
  • Please bring to your exam
    • insurance benefit card
    • current glasses/sunglasses
    • contact lenses
    • mask or equivalent face cover
  • 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 Coherance Tomography (OCT-Disc and/or Macula) & Analysis; and Baseline Fundus Photography.

    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 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.

    • Providing my insurance card information to enable Freelton Eye Care to bill directly for my visit and accept payment on your behalf, when applicable.
    • Accepting payment receipts and glasses prescriptions via email.
    • Providing my personal health information to ensure the time I spend in the office is efficient and focused on my medical care.
    • Application of a $100 charge on the officially-booked appointment date if I do not attend my appointment OR cancel with fewer than 2 business days’ notice.
  • I, have read the information on this form and DO CONSENT to the above.
  • MM slash DD slash YYYY

Revised Handout 2021 03 30(1) page 001