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Between Church and Wellington on Queen St.

Between Church and Wellington on Queen St.

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Home » Contact Us » online medical needs form

online medical needs form

  • 1. Patient Information

  • Date Format: MM slash DD slash YYYY
  • Insurance Information

  • Health Card Information
  • Date Format: MM slash DD slash YYYY
  • As per the Canadian Anti-Spam Legislation, I am providing my Express Consent to communicate electronically. I understand that my consent may be withdrawn at any time by emailing hello@stmarysoptometry.ca
  • 2. Personal medical history

  • Purpose of your visit

  • Corrective lens information

    Your answers to these questions will guide us in recommending the best products to meet your eyewear needs.
  • 3. Visual Needs

    Your answers to these questions will guide us in recommending the best products to meet your eyewear needs.
  • a) Employment Information
  • b) Job Description
  • c) Which do you do regularly?
  • d) Hobbies/Recreation
  • g) What is important when choosing your new glasses?