Visionary Eyecare - Optometrists Dr. Kirby Lam, Dr. Louis Blanchette and Dr. Elena MacLeod

Clearer vision for a better life.

Patient Intake Form

This form is for new patients only and should only be filled out if you have never visited our office before.

You will need to book your appointment separately. This is not a request for an appointment.

Patient Intake Form
First
Last
Do you have a valid driver's license? *
Reason for your visit (check all that apply): *

Personal Medical History

Please check all that apply:
Allergies to medications? *
Do you have other allergies? *
Do you smoke? *

Personal Ocular History

When was your last visit to an optometrist? *
Do you use a computer on a daily basis? *
How long?
Have you ever worn/are you wearing contact lenses? *
Have you ever had eye surgery? *
What type? *
Have you ever had an eye injury? *
Have you or a family member had any of the following eye problems/diseases? *