Skip to main content

2 Locations in Kingston: Concession Street and Innovation Drive

Book Appointment

Order Contact Lenses & Retail Products

Call Us! 613-546-5744

Hours & Locations
Our Team
- Our Optometrists
- Our Staff
Eye Care Services
Eyewear
- Eyeglasses
- Optical Lab
Kids Zone

Hours & Locations
Our Team
- Our Optometrists
- Our Staff
Eye Care Services
Eyewear
- Eyeglasses
- Optical Lab
Kids Zone

Home » Contact Us » Patient Intake Forms » Child Patient Intake Form

Child Patient Intake Form

"*" indicates required fields

Full legal name*

First Last

Prefers to be called*

Assigned Sex at Birth*

Preferred Pronouns*

Parents/caregivers names*

List family members who are patients of the clinic*

Emergency contact & phone number

Name*

First Last

Phone*

Reason for the patient’s visit today*

Name of Family Doctor/Specialists*

First Last

Previous Eye Doctors (if any)*

First Last

Please provide a list of medications to our staff to photocopy or if brief write them here:*

Allergies (environmental &/or to medications)*

Birth history*

Normal

Premature

Unknown (eg. adopted)

Other

Explain

Is the patient meeting developmental milestones (please explain)?*

Did any members of the patients’ family have any conditions that affect the eyes at a young age (eg. strong glasses, patching, lazy eye )?*

Yes

No

Please explain

List any eye operations or injuries (type)*

Date

Has the child ever worn glasses or contacts ?*

Yes

No

Type

Grade in school*

Hobbies*

Insurance provider*

Green Shield

Great West Life

Blue Cross

Sunlife

OW

ODSP

IA

DVA

CAS

Other

How did you hear about us?*

Our website

Google

Yellow Pages

Referral

Other

Please name

Please explain

Parent signature*

Missed appointments and/or cancellation policy

At St. Lawrence Optometry, we strive to provide excellence in patient-centered eye care and ocular health. Part of that service may mean you are called back for follow-up appointments, most of which we make at the end of your initial visit with us.

If for some reason you are unable to make a booked appointment, whether for a full exam or follow up, we ask that you notify us by phone/email/in person 24 hours in advance of your scheduled appointment time. This policy is in place given the limited availability of appointment spots.

Please note that there is a $70 missed appointment fee for those that do not comply with this cancellation policy

I certify that I have been made aware of this policy and agree to maintain my scheduled appointments to the best of my ability. I understand that in certain instances, I may be charged the $70 missed appointment fee if I fail to give 24 hour notice of missing my appointment

Patient name*

First Last

Patient signature*

Date*

MM slash DD slash YYYY

Examining Doctor*

Δ

Search:

Book An Appointment

Order Contacts Online

St Lawrence Optometry Downtown

265B Concession Street
Kingston, ON K7K 2B7

Phone: 613-546-5744
Fax: 613-549-4510
Email: info@slvision.ca
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 5:30 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: 8:00 AM - 4:30 PM
Saturday: Closed
Sunday: Closed

Please call our clinic to confirm operating hours as they are subject to change without notice.

St Lawrence Optometry East

677 Innovation Drive, Unit 5
Kingston, ON K7K 7E6

Phone: 613-544-2320
Fax: 613-544-1626
Email: infoeast@slvision.ca
(Do not send personal health information by email.)

Monday:8:00 AM - 5:30 PM
Tuesday:8:00 AM - 5:30 PM
Wednesday:8:00 AM - 5:30 PM
Thursday:8:00 AM - 5:30 PM
Friday:8:00 AM - 4:30 PM
Saturday:Contact the office for hours
Sunday:Closed

Currently under innovation. Please contact for more information.

Please call our clinic to confirm operating hours as they are subject to change without notice.

Home
Insurance
Contact Us
What’s New
Disclaimer
Privacy Policy

Home
Insurance
Contact Us
What’s New
Disclaimer
Privacy Policy

Schedule Appointment

St. Lawrence Optometry is situated on the traditional land of the Anishinaabe, Haudenosaunee, and Huron-Wendat Peoples. Today, this community is home to many Indigenous people and settlers from across Turtle Island.

Speak Field

St Lawrence Optometry East - Located at 677 Innovation Drive, Unit 5, Kingston, ON K7K 7E6. Phone: 613-544-2320 . https://www.slvision.ca

St Lawrence Optometry Downtown - Located at 265B Concession Street, Kingston, ON K7K 2B7. Phone: 613-546-5744 . https://www.slvision.ca

© 2024 Powered by

Accessibility
Sitemap
Privacy
Disclaimer
Login