(705) 746-1212

3 Church St. Parry Sound, Ontario. P2A 1Y2

Welcome Form

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* Required information.

We welcome you to our practice and ask that you kindly complete or correct all information on this form.

Name *
Date of Birth
Family Doctor
Mailing Address
Email Address *
Occupation
Home Phone
Work Phone
Cell Phone
Do you or your family have any history of the following conditions? (check all that apply)
Glaucoma
Cataracts
High Blood Pressure
Macular Degeneration
Heart Problems
Retinal Degeneration
Stroke
Thyroid Condition
Crossed/Lazy Eyes
Asthma/Allergies
Color Blindness
Arthritis
Do you or your family have any history of the following conditions that were not asked?

 


 

Do you currently have any of the following symptoms? (check all that apply)
Blurry Distance Vision
Poor night Vision
Eye Strain
Blurry Near Vision
Trouble Reading
Itchy Eyes
Discharge
Watering
Pain in the eye
Burning Eyes
Sandy/Dry Eyes
Red Eyes
Glare/reflections
Discomfort in sunlight
Double Vision
Flaoters or spots in vision
Flashes of light
Eye injury
History of eye surgery
Headaches
Pain

 


 

 

Are you interested in any of the following? (check all that apply)
New Spectacles
A new prescription
Light weight glasses
Anti-reflective lens
Contact lenses
Sunglasses
Clip-ons
Safety Glasses
Laser Eye Surgery
Contact Lenses
Dry eye therapy

 


 

 

How were you referred to us?
Previous patient of Dr. Axt
Yellow Pages
Family Doctor
Another Patient
Google/Internet Search
Medications
Allergies