Family Doctor

Health Card # and Version Code

Date of Birth

Select License Class G - Regular License G1 - Level 1 of graduated licensing G2 - Level 2 of graduated licensing M - Motorcycle M1 - Level 1 of graduated licensing for motorcycles M2 - Level 2 of graduated licensing for motorcycles Other No License Driver's License Class

Select Yes No N/A Do you need to wear glasses while driving?

Please list all eyeglasses you use and briefly describe their purpose.

Select Yes No Do you wear contact lenses?

Please provide your brand, lens type, and prescription details.

Select No Yes Do you currently have vision insurance?

Please provide a list of all known drug allergies.

Please provide a list of all known general allergies.

Please list any other medical conditions.

Please list all other current medications and their purposes.

Please list any other eye conditions you've had, including injuries or surgeries.

Please list any other eye conditions that are present in your family.

Select Online Search Social Media Patient Referral Family Doctor Word of Mouth Walk-in/Storefront Advertisement Event/Community Outreach Other