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Hello and welcome to the Nation's Vision Intake Form

Hello and welcome to the Nation's Vision Intake Form

This form will enable you to sign up for a Nation's Vision Eye Exam or Nation's Vision Glasses Fitting. To schedule an appointment, complete the brief form and provide a requested date and time. The clinic is hosted at The Genesis Centre (7555 Falconridge Blvd NE #10, Calgary, AB T3J 0C9). Please note, when you arrive, you must go to the front desk down stairs and ask to be directed to the FGMPR. Signage will be available for further directions. Please follow the instructions and fill out and submit this form for us to book you into our clinic.  Please note, if you do not see your preferred date or time, it is likely we do not have clinic on that date or the clinic is fully booked. If you have any questions feel free to email us at info@nationsvision.ca or call us at (587) 997-4896.

HIPAA

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    Please select one option below. If you intend to schedule several eye exams (multiple children or family members), please complete this form for each patient, separately.
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    Pick a Date
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    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
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    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
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    • Bolivia
    • Bosnia and Herzegovina
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    • Burkina Faso
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    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
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    • China
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    • Latvia
    • Lebanon
    • Lesotho
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    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
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    • Mozambique
    • Myanmar
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    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Select your child's grade from the list below. If your child attends a school with split grades, select the lower of the number of the split grades.
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    I confirm that I have the legal authority to provide consent for service. I understand that services provided by Nation’s Vision are not a specific activity or service provided by the school and participation in the above services is voluntary. Nation’s Vision collects information in accordance with Section 20 of the Health Information Act (HIA) for providing health services, determining eligibility for health services, or to carry out any other purpose authorized by the HIA. If you have any questions about this collection, please ask our Nation’s Vision team.
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    Please remember to bring your Alberta Health Card to the clinic. If you have ANY other form of health benefits including NIHB, IFHP, AISH, ALBERTA WORKS, ETC, please also bring this information along to the clinic.
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