FORM 10: Existing Patient INFO UPDATE

Dr. Bream & Associates

Form 10: Existing patient INFO UPDATE
If you are an existing patient of our clinic, and if you require any information update such as email, address, last name, health card version code, phone number, insurance provider information etc., please fill this form 24 hours PRIOR to your appointment with our physicians.

Thank you
EYETELLIGENCE Team

PATIENT PROFILE
Today's Date

MonthDayYear
Optometrist

Dr. Sukanthy BreamDr. Lillian WonDr. Graham O'Brien
Your appointment Date & Time:*

MonthDayYear
Hour MinutesAM/PM Option
Name (exactly as shown in your health card)*

First NameLast Name
OHIP Number (MUST be valid)*
OHIP Version Code*
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell Phone (For the purpose of appointment reminder TEXT messages)
Work Phone
Home Phone
Please enter a valid phone number.
Email (reminders, forms, invoice, prescription, educational material will be sent to your email)
Preferred Contact
2nd Preferred Contact
Occupation (or Grade)
Employer (or School)
Spouse's (or Parent's) Name
Do you drive?

YesNo
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?*

YesNo
Your Appointment Type:*

Adults 20-64: Comprehensive ANNUAL visual assessmentAdults 20-64: Follow-up consultations if requiredChildren – Under the age of 20 with OHIP eligibility, Comprehensive ANNUAL or FOLLOW-UPComprehensive ANNUAL visual assessment with OHIP eligibilityFOLLOW-UP consultation with OHIP eligibilityContact Lens FittingOther
Do you have any insurance contribution through your employer/private or through a family member?*

YesNo
Provider*
INSURANCE CONTRIBUTION: If you, parents or spouse have any private insurance contribution, please provide. We only need this information in the event you would like us to help you with direct claim. We strongly suggest you call your insurance provider to find your *eligibility* *coverage* *any health expense amount* and if your plan *permits direct payment to your healthcare provider* prior to the appointment. Insurance providers are only available to answer between M-F 8am-4pm. PLEASE ENTER "NONE" IF YOU DO NOT HAVE ANY OF THE SPECIFIC INSURANCE COVERAGE.
OTHER*
Family Doctor
Date of Last Physical

MonthDayYear
Name*
Signature Date*
Signature*

Clear
Should be Empty:

Dr. Bream & Associates