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NOTE: If you are unsure about your prescription, please enter "0" in both fields. Your prescription will be determined and verified during your pre-operative evaluation.
HomeFormsPatient Information Sheet
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Patient Information Form
(All information is confidential)
All fields must be completed in order to submit this form.
Personal Information
First name
  Last name
Address
  City/Town
Country
 
Province/State
Postal Code/ZIP
Email address
  Phone number
(   )  -
Date of birth (DD / MM / YYYY)
/ /  yrs old 		  Business number
(   )  -
Occupation
   Do you have a pilot's license?
Yes  No
If you are coming from out of town, please indicate where we can reach you:
   Your prescription:
Right eye (OD)
   Left eye (OS)
If you are unsure about your prescription, please enter "0" in both fields. Your prescription will be determined and verified during your pre-operative evaluation.
 
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