• Dr. Bream & Associates

    Form 1: PATIENT INTAKE

  • Welcome to our clinic. We are pleased to offer this online form to our patients in order to reduce the waiting times and the exposure in a public setting.

    The Patient Intake Form must be completed 24 hours PRIOR to your appointment with our physicians.

    The information provided is strictly confidential.

    Please fill out this application completely to the best of your ability.

    A copy will be sent to your email address given in this form.

     

    Thank you
    EYETELLIGENCE Team

  • PATIENT PROFILE

  • Today's Date
     - -
  • Optometrist
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you drive?
  • Does the staff who booked the appointment, clearly communicated the professional fee for your appointment along with any additional "non-OHIP" service fees in the event it is required by the physician?*
  • Your Appointment Type:*
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  • Image field 170
  • Image field 171
  • Image field 172
  • Image field 173
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  • I hereby acknowledge that I have thoroughly reviewed and understand the payment policy, and I agree to adhere to its terms and conditions.*
    • Private insurance and other Healthcare Providers 
    • Do you have any insurance contribution through your employer/private or through a family member?*
    • *
    • Date of Last Physical
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date of Last Eye Exam
       - -
      2 digit month, 2 digit day, 4 digit year
    • Referral Source 

  • OCULAR HEALTH HISTORY

    • Eye Glasses 
    • Do you wear eye glasses?
    • If No, have you ever worn eye glasses?
    • What type of eye glasses
    • Do you wear UV protection sunglasses?
    • Do you buy eyeglasses online?
    • Contact Lens 
    • Do you wear contact lenses?
    • What type of contact lenses?
    • If No, have you ever worn contact lenses?
    • Are you interested in wearing contact lenses?
    • Are you having problems with your current contact lenses?
    • Surgeries and Problems 
    • Have you ever been diagnosed or have ever experienced any of the following conditions?(Select all that apply)
    • Have you had any eye surgery?
    • Have you had any form of refractive surgery?
    • What kind is it?
    • When it was done?
       - -
      2 digit month, 2 digit day, 4 digit year
    • Are you interested in refractive surgery?
    • Please indicate any family history of the following eye conditions.

  • MEDICAL HISTORY

  • Do you smoke?
  • Do you have any allergies to medications or anything else?
  • List all current medications (Prescription, over the counter and/or herbal)
    Rows
  • Are you pregnant and/ or nursing?
  • Do you have any of the following medical conditions?(Select all that apply)

  • HOBBIES & INTERESTS

  • Sport Activities
  • Hobbies
  • Other Interests
  • Signature Date*
     - -
  • Should be Empty: