(705) 746-1212

84 Church St, Parry Sound, ON P2A 1Z1

UPDATE
Our office is now open and scheduling appointments for examinations, repairs, frame selection and pick ups. Priority is being given to those with urgent care needs. Please visit our online store for contact lens, dry eye care, and accessory purchases.

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
OHIP #
Vision Insurance Company
Do you 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
Diabetes
Does anyone in 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
Diabetes
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