Eyecare Kingston - Dr. Michael Lewis and Dr. Andrew Lewis

Call (613) 507-0707

745 Gardiners Rd. Unit 3

Kingston, ON K7M 3Y5

Open Hours

Mon - Thu: 8:30am - 5:00pm

Fri: 8:30am - 4:00pm

Appointment Request Form - New Patients

This form is for new patients wanting a comprehensive eye exam. If you require any other appointment type, aside from a full comprehensive exam, please call our office.

If you do not require an eye appointment and ONLY require an appointment with one of our Opticians for a repair, pick-up, or adjustment, please use our Contact Us form, and one of our opticians will contact you directly.

Please refer to our Pricing Policy if you have any questions about our fees. Our online forms are secure and PIPEDA compliant.

Patient Information Preferred Doctor * Please select an item. Ontario Health Card Number and Version Code* (no dashes or spaces) Please enter your Health Card Number and Version Code. Patient Full Name * (as it appear on Health Card) Please enter your full name, as it appears on your Health Card. Preferred Name or Nickname Date of Birth*(mm/dd/yyyy) Please enter your Date of BirthInvalid format. Full Name of Family Doctor* Please enter your family physician. Preferred Phone: * Please enter your phone number. Alternate Phone: Please select an item. Address * Please enter your full address. Email
Gender * Driver's License Class* Please select a Driver's License Class. Are you required to wear glasses while driving?* Please select an item.
Vision Insurance Do you have any vision insurance?* Please select an item. By completing the information below, I certify that I agree to the
Vision Insurance Consent - Terms and ConditionsInsurance Company Name Primary Member's Name (If you are NOT the primary insured member) Policy/Plan Number MemberID
Patient Allergies Are you allergic to any medications?* Please select an item. Please list all drug allergies. Do you have any general allergies?* Please select an item. Please list all general allergies.
Patient Medical Conditions Do you have any of the following medical conditions?* Yes No --- Diabetes Type 1 Yes No --- Diabetes Type 2 Yes No --- Heart Disease Yes No --- High Blood Pressure Yes No --- Have you ever had a Stroke? Please specify date or year of stroke. Yes No --- Do you smoke?
Please list all other medical conditions? Have you ever had any serious eye injuries, infections, and/or surgeries? Please list all serious eye injuries, infections, and/or surgeries. Please include the date or year it happened, a brief description, which eye was affected and which Doctor performed treatment.
Patient Medications Are you currently taking any medications?* Please select an item. Please list all current medications and reason for taking them.
Family Ocular History Have any immediate families members (parents, siblings, children) been diagnosed with the following?* Yes No --- Macular Degeneration Please specify which family member(s). Yes No --- Glaucoma Please specify which family member(s). Please list any other eye conditions that run in your family:

Referrals How did you hear about us? Please select an item. Please let us know the Patient's Full Name, so we can send them a thank you note and a gift card. Please let us know whether you prefer Starbucks or Tim Horton's? One of the finest compliments a practice can receive is a referral of friends and family. We sincerely appreciate when a patient recommends our services, and we want to let them know, by sending them a thank you note with a gift card. So please let us know which gift card you'd prefer, in case you choose to recommend us.
Eyewear Please list all the eyeglasses you use regularly and a brief description of what you use them for. Are you a contact lens wearer?* Please select an item. Please list your Brand, Lens Type and Prescription below. Do you want your contact lenses assessed? *Additional fees apply.
You can alter decision at time of appointment.

Comprehensive Eye Exam Request

If you prefer to see a specific doctor, please make sure to check the doctor's schedule before requesting a time. Click Here to View Doctors' Schedule
Appointment 1st choice * Please select an item. Please select an item. Please select an item. Appointment 2nd choice Reason for Appointment and Additional Comments * (eg. Routine Exam, Need New Glasses/ CLs, Medical/Other Concern) A value is required. Do you Require an Appointment with the Optician in our Optical Gallery?* Please select an item.

All questions marked with an * must be completed for the submit button to work.