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

Online Patient Intake Form

Please complete the following form prior to your first appointment. Our online forms are secure and PIPEDA compliant.

Patient Information Please select an item. Please enter your Health Card Number and Version Code. Please enter your full name, as it appears on your Health Card. Please enter your Date of BirthInvalid format.

Please enter your family physician.

Please select a Driver's License Class. Please select an item.
Eyewear Please select an item.
Vision Insurance Please select an item. By completing the information below, I certify that I agree to the
Vision Insurance Consent - Terms and Conditions

Patient Allergies Please select an item. Please select an item.
Patient Medical Conditions

Patient Medications Please select an item.
Family Ocular History

Referrals Please select an item.

COVID-19 Screening Precautions

I certify that I will not come to my appointment if any of the following apply:
1. I have cold or flu like symptoms (such as fever, cough, shortness of breath, sore throat, runny nose, sneezing, difficulty swallowing, nausea, chills, headache).
2. I have travelled outside Ontario or have had close contact with anyone that has travelled outside Ontario within 14 days of my appointment.
3. I have had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19 within 14 days of my appointment.

You must certify that you agree to COVID Screening Precautions.
All questions marked with an * must be completed for the submit button to work.