Eye Exam Child Intake Form | Optometry Clinic Vancouver

PATIENT INFORMATION

First Name*

Last Name*

Date of Birth*

Parents Name*

Home Phone*

Cell Phone

Email*

Who may we thank for referring you to our office?

Family/Friend

Professional Referral

Source's Name

If not referred, how did you choose our office?

VISUAL HEALTH

Date of Last Eye Exam

By Whom?

Do you currently wear glasses?

Yes

No

Any problems with your current contacts or glasses

Use Sports Goggles/Safety Glasses

Yes

No

PATIENT MEDICAL HISTORY

Name of Family Physician

Physician Address

Date of Last Physical Check-up

CURRENT MEDICATIONS (RX or Over the Counter)

Allergies to medications?

Yes

No

If so, please list:

Child
Intake Form