New Patient lntake Form
Welcome to CLEAR eye doctors. To ensure a safe and efficient visit for you, we would like you complete and submit this Intake form which will help appropriately schedule your appointment and prepare for your individual needs before your appointment. There are 6 sections to this form. This information is strictly confidential. However, if you prefer not to submit online, please email us at info@cleareyedoctors.com or call us at 416-463-9900 and we can email you a PDF version. Thank you for your cooperation.
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Email *
Last Name  (on your OHIP (Health) card) *
First Name  (on your OHIP (Health) card) *
Nickname (what name you like to go by)
Maiden Name or Other Last Name
Date of Birth *
MM
/
DD
/
YYYY
Gender: *
Prefix:
Clear selection
Preferred Pronoun:
Preferred Phone Number *
Preferred Phone Number Type *
Home Address  ( Street Number & Name, City, Province, Postal Code, Country) *
Do you drive? *
Occupation or Grade in school: *
Employer or School: *
How did you hear about us: *
If you were referred, whom may we thank? Or please describe other:
Health Card Card # and Version Code if you have not already provided it, if so please state Gave It *
Captionless Image
Emergency Contact (or Parent/Guardian for Minor or Partner/Spouse)   *
LAST NAME - Emergency Contact *
FIRST NAME -Emergency Contact *
PHONE - Emergency Contact *
TYPE OF PHONE - Emergency Contact *
EMAIL - Emergency Contact
Do you have a family doctor? *
Family Doctor Last Name
Family Doctor First Name
Family Doctor Phone Number
Family Doctor Address OR Major Intersection
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