Welcome Form - Specsavers SouthCentre - Theo Buzea Professional Corporation
Welcome to our clinic! To ensure an easier journey where we can provide you with the best standard of care, we kindly ask you fill out the information below and sign at the bottom. Please note certain information is required in order to proceed. Any heading with a * beside it is required.
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Address
Street Address
Street Address 2
City
Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number
Email
*
Please enter a valid email
Alberta Health Care Number
If out of province or no AHC number please mention instead of putting number
Family Physician Name
Leave empty if no family Physician
Family Physician Clinic
Leave empty if no family Physician
How did you find our clinic?
Please Select
Family/Friends
Online
Location
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What is the reason for this visit?
Please Select
Routine
Eye Concern
Other - Please fill below more details
Reason for visit details
Only fill this if selecting "other" for the question above
Do you wear contact lenses?
Please Select
No, and not interested
No, but I'm interested
Yes - please fill the brand below
Brand of contact lenses
Only fill this if selected "yes" for the question above
Do you wear glasses?
Please Select
Yes - for distance
Yes - for near
Yes - for distance and near
No glasses
Please note the Doctor and Technician will be asking you about general health, medications, allergies, history of eye issues or surgery, and family history of any health issues or eye problems. To ensure the most accurate assessment of your vision and prescription needs, we kindly ask that you provide any current or previous glasses and/or prescriptions. If these are not provided, you acknowledge that the absence of this information may increase the risk of discrepancies in your new prescription. This could lead to adaptation issues, such as dizziness or headaches, particularly if the change is significant. Additionally, we rely on the accuracy and completeness of the information you share with us during your visit. Please understand that any missing or incorrect details may affect the outcome of your examination.
*
I understand
I certify that I have read the above information and answered the questions accurately. I certify that I have sought out and want to be under the care of Dr. Theo Buzea & Associates at Specsavers. I authorize the centre to use my information for the purpose of providing me healthcare. This includes permission to direct bill any insurance provider I have requested them to do so for. I acknowledge and understand HIPAA privacy standards. I certify that I am the individual listed above and submit my digital or physical signature below to accept all the terms and conditions listed in this form.
*
I understand and agree
Today's Date
*
-
Day
-
Month
Year
Date
Signature
*
Please use finger to sign
Continue
Continue
Should be Empty: