2901 Markham Rd Unit 8, Scarborough, ON | 416-335-1234 / 1-888-407-EYES

Forms

Filled by ALL NEW patients 24 hrs PRIOR to your visit:

FORM 1: New Patient Intake

FORM 2: Patient Electronic Communication Consent

FORM 3: Patient Consent for Collaborative Care

Only filled by patients who wants direct claim of 3rd part insurance.

Please check your eligibility & coverage with your provider PRIOR to your appointment.

FORM 4: TELUS Insurance Benefit Assignment Form

FORM 5: TELUS Electronic Transmission Authorization & Consent

Only filled by patients who require Contact Lens fitting:

FORM 6: Contact Lens Consent Form

Only filled by patients who wants to use their own eyeglass frame to order their new lens:

FORM 7: Patient’s Own Frame Waiver

Filled by Patient who wants to disclose their records to a 3rd party (e.g.: Lawyer, Insurance provider, Care provider)

FORM 8: Consent To Disclose Personal Health Information

Filled by anyone who wants to use an expired prescription OR a prescription from a physician outside our clinic:

FORM 9: Consent To Use Expired Prescription OR From Another Physician Outside Our Clinic

Filled by the existing patients to update their profile ( e.g.: Change of address, name, health card version code, phone, email etc.)

FORM 10: UPDATE of your records