Welcome to Petrolia Optometry! Please take a moment to verify and / or update the information below. For privacy reasons, we prefer to not confirm this information out loud in front of others in the waiting area. Thank you!

Patient Name:

OHIP Number:

D.O.B

Family Physician:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number:

Alternate Phone Number 1:

Phone number Please specify phone type (work, cell, etc)

Alternate Phone Number 2:

Phone number Please specify phone type (work, cell, etc)

Please specify which of the above is your preferred contact number.

Email Address:

Alternate Contact:

(reachable at a different number than the ones listed above)

Contact Name: Relationship: Contact Phone Number:

Guardian Information for Child Patients

Guardian 1

First Name Last Name Relationship

Guardian 2

First Name Last Name Relationship

PLEASE PRESENT A LIST OF MEDICATIONS TO RECEPTIONIST OR LIST BELOW:

Allergies:

For NEW Patients: How did you hear about Petrolia Optometry?

If you were referred to us by another patient, please specify his/her name:

Petrolia Optometry is pleased to announce that we will be offering a new way to contact you in the near future! Please take a moment to fill out the section below:

For appointment reminders, please select any and all methods we may use to contact you:

Text Message
Email
Phone

For Order Updates (For glasses and contact lens orders), please select any and all methods we may use to contact you:

Text Message
Email
Phone

For Patient Recalls (Reminders to see your optometrist), please select any and all methods we may use to contact you:

Text Message
Email
Phone

May we contact you with the following information:

Eye Health Education
Information about upcoming sales and promotions
Newsletters

We need your consent IN WRITING to send ANY of your personal health information to ANYONE. Please check off all providers that you give us permission to send information/reports to WHEN REQUIRED.

Family Physician
Another Eye Care Professional (ie. ophthalmologist or optician)
Medical Specialist (ie. a rheumatologist or internist)
Nursing Home or Hospital
Family Member

Please specify which family member(s):

I have read and understand the above information

Please type your full name:

Please sign:

Date:

Patient History Form

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Petrolia Optometry