Intake Form

Eye Exam $ 130. Eye Exam for Children 18 and under and Seniors 65 and Older -$30 (Balanced Billing with AB). If you have insurance, please present this with your from to predetermine your coverage
First Name*
Last Name*
Cell*
Email*
example@example.com
Address*
Postal Code*
GP NAME/MEDICAL CLINIC
Alberta Health Care*
Insurance Name
Policy Number
Group ID
Date Of Birth*

MonthDay Year
Date
I understand that I am responsible for all fees charged, and if Alberta Health Care rejects any claims I will pay the full amount. (Select Box) : Privacy*

I consent to the collection, use and disclosure of my/my dependent’s personal information as set out in the privacy statement.
Should be Empty: