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

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

Adult Patient Intake Form

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.
*Fields marked with an asterisk are required and must be completed before submitting.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Date*
MM slash DD slash YYYY
Patient Information
Full Legal Name*
Prefix First Last Suffix
Preferred Name*
Assigned Sex at Birth
Pronouns
Emergency Contact*
Contact's Phone #*
Patient Email Address*
May we contact you via email?*
- Yes
- No
May we contact you via text?*
- Yes
- No
How did you hear about our clinic?*
Website/Google/Yellow page/Referral (name)
Personal Information
Date of Birth (mm/dd/yyyy)*
Occupation*
Hobbies*
(certain hobbies have unique visual demands)
Family Doctor*
Date of last medical exam.*
Medications*
(please provide a list to be scanned if possible)
Allergies*
(please include drug and environmental)
Are you or could you be pregnant/nursing?*
- Yes
- No
If pregnant, how many weeks?
Are you or were you ever a smoker?*
When did you quit?
Reason for seeking an eye examination today.*
When was your last eye exam?*
Glasses & Contacts History
Do you presently wear glasses?*
- Yes
- No
List what type/s
Do you presently wear contact lenses?*
- Yes
- No
What brand and type
Eye History
Are you currently under the care of an ophthalmologist?*
- Yes
- No
Please provide the name
Have you ever been diagnosed with an eye disease?*
- Yes
- No
Please list
Have you ever had surgery on your eyes?*
- Yes
- No
Please provide details and dates
Have you ever had any injuries to your eyes?*
- Yes
- No
Please provide details and dates
Are you interested in wearing contact lenses?*
Do you have a driver's license?*
- Yes
- No
What class license do you have?
Are you required to wear corrective lenses (glasses or contacts) while driving?*
- Yes
- No
Personal and Family Ocular and General Health History
Glaucoma*
- No
- Self
- Family
Family (list relationship)
Cataracts*
- No
- Self
- Family
Family (list relationship)
Macular Degeneration*
- No
- Self
- Family
Family (list relationship)
Strabismus ("turned eye")*
- No
- Self
- Family
Family (list relationship)
Amblyopia ("lazy eye")*
- No
- Self
- Family
Family (list relationship)
Other eye diseases (Retinal Detachment)*
- No
- Self
- Family
Family (list relationship)
Diabetes*
- No
- Self
- Family
Family (list relationship)
High Blood Pressure*
- No
- Self
- Family
Family (list relationship)
Thyroid Disease*
- No
- Self
- Family
Family (list relationship)
Arthritis*
- No
- Self
- Family
Family (list relationship)
Insurance Provider
Please bring all insurance cards with you to your appointment.
Insurance Provider: (ie Great West Life, Manulife)*
Missed Appointments and Cancellation Policy
Scheduled Appointments*
I have read and agree to the below 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.
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Email
This field is for validation purposes and should be left unchanged.

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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.

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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.

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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

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