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Located at 119-125 Village Green Square Scarborough

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Home » Contact Us » Medical History Form

Medical History Form

"*" indicates required fields

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Contact Details

Medical History

Include Name of Medication, Dosage, Frequency Taken
Do you have any allergies to medications?
Check any of the following that you have had:
Check any of the following that your family have had:
Reason for visit (check all that apply)
Are you interested in
How did you hear about this office
Clear Signature
Select date MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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NEW WEARER REBATE

Purchases of participating ACUVUE products must be made in-office between Janurary 1 to June 30, 2025** with rebate submission on or before July 31, 2025.

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