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Drs. Wilkinson, Runstedler, Cottreau & Barth

Located at 1342 King St. E. Kitchener, Ontario N2G 2N7

Hours & Location
Our Eye Doctors
The Staff
Eye Care Services
Our Eye Care Clinic
Eyeglasses & Contacts
Insurance

Hours & Location
Our Eye Doctors
The Staff
Eye Care Services
Our Eye Care Clinic
Eyeglasses & Contacts
Insurance

Drs. Wilkinson, Runstedler, Cottreau & Barth

Located at 1342 King St. E.
Kitchener, Ontario N2G 2N7

Hours & Location
Our Eye Doctors
The Staff
Eye Care Services
Our Eye Care Clinic
Eyeglasses & Contacts
Insurance

Hours & Location
Our Eye Doctors
The Staff
Eye Care Services
Our Eye Care Clinic
Eyeglasses & Contacts
Insurance

Schedule an Appointment

Call Us! 519-576-6460

Bloom-02-1280X853-e1496089667347

Home » Contact Us » Patient Registration Form

Patient Registration Form

Patient History Form

J.M. Wilkinson B. Sc., O.D., FAAO.
T.M. Runstedler B. Sc., O.D.
C.C. Cottreau B. Sc., O.D.
C.N. Barth O.D.
- Mr.
- Mrs.
- Miss.
- Ms.
- Dr.
Name
First Last
Todays Date
Street address
City
- Ont.
Postal code
Home phone
Cell phone
Work phone
Ext.
Health card #
Birth Date
Referred by
Email
Occupation
Hobbies
Current medical physician
Current ophthalmologist / optometrist

	No	Yes - self	Mother	Father	Sister / Brother	Grandfather	Aunt / Uncle
Glaucoma
Cataracts
Turned Eye
Strong Glasses
Retinal detachment
Color vision defects
Diabetes
High blood pressure
Heart disease
Hardening of the arteries
Blood disorders
Thyroid conditions
Arthritis

Other diagnosed eye or body diseases / conditions
Do you or did you have any of the following
Eye injury
- Yes
- No
If yes please explain
Headaches
- Yes
- No
If yes please explain
Eye surgery
- Yes
- No
If yes please explain
Allergies (please name)
Drugs
General
Are you currently taking medications
- Yes
- No
List medications
Do you wear glasses?
- Yes
- No
- Distance
- Near
- Both
Do you wear contact lenses?
- Yes
- No
Year Obtained - Soft 20
Hard 20
Gas permeable 20
What is the reason for your visit?
Signature

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Patient History Form

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Drs. Wilkinson, Runstedler, Cottreau & Barth

1342 King St. E.
Kitchener, ON N2G 2N7

Email: kweyedocs@gmail.com
(Do not send personal health information by email.)
Phone: 519-576-6460

Monday: 9:00 am - 8:00 pm
Tuesday:9:00 am - 5:00 pm
Wednesday:9:00 am - 5:00 pm
Thursday:9:00 am - 6:00 pm
Friday:9:00 am - 4:30 pm
Saturday:9:00 am - 12:00 pm*
Sunday:Closed

Office is closed for lunch from 12:45 - 1:45 daily.
*Not always available so call the office prior to visiting.

Hours & Location
Our Eye Doctors
The Staff
Eye Care Services
Our Eye Care Clinic
Eyeglasses & Contacts
Insurance

Hours & Location
Our Eye Doctors
The Staff
Eye Care Services
Our Eye Care Clinic
Eyeglasses & Contacts
Insurance

Home
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Home
Contact Us
What’s New
Disclaimer
Privacy Policy

Drs. Wilkinson, Runstedler, Cottreau & Barth - Located at 1342 King St. E. , Kitchener , Ontario , N2G 2N7. Phone: 519-576-6460. http://www.kweyedocs.com/

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