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Name: Mstr.Mr.Mrs.MissMs.Dr.
D.O.B. mm/dd/yyyy / /
Sex: MaleFemale
Mailing Address:
City: Province: Postal Code:
Alberta Health Care Number:
Email Address (for appt reminders and contacts only):
Phone: (Cell): (Home): (Work):

How did you hear about our office? (Please check the appropriate box)
LensCraftersSears OpticalFamily/FriendsYellowpagesOnlineWalk-InOther

When was your last eye exam?
Name of Optometrist Office
Are you planning on purchasing glasses? YesNo


Medical History

*Since certain conditions are hereditary, it is important that we know you and your families health history to better care for your vision. Please be prepared to provide us with any medical history you may have including your vision history
List any Medications:
List any Allergies:

The above information is truthful and to the best of my knowledge. I understand that I am responsible for all fees charged, and if AHC rejects any claims I will pay the full amount.

Emergency Contact:
Phone Number: