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 addressCity Ont. Postal codeHome phoneCell phoneWork phoneExt.Health card #Birth Date Referred byEmail OccupationHobbiesCurrent medical physicianCurrent ophthalmologist / optometristNoYes - selfMotherFatherSister / BrotherGrandfatherAunt / UncleGlaucomaCataractsTurned EyeStrong GlassesRetinal detachmentColor vision defectsDiabetesHigh blood pressureHeart diseaseHardening of the arteriesBlood disordersThyroid conditionsArthritisOther diagnosed eye or body diseases / conditionsDo you or did you have any of the following Eye injury Yes No If yes please explainHeadaches Yes No If yes please explainEye surgery Yes No If yes please explainAllergies (please name)DrugsGeneralAre you currently taking medications Yes No List medicationsDo you wear glasses? Yes No Distance Near Both Do you wear contact lenses? Yes No Year Obtained - Soft 20Hard 20Gas permeable 20What is the reason for your visit?Signature
Office is closed for lunch from 12:45 - 1:45 daily.
*Not always available so call the office prior to visiting.