ENFR

Printable · for optometrists

Pre-exam questionnaire

Print it, hand it to the client on arrival, keep it in the file. The text below is the same one clients sign when they book online through the booking software.

Printable · Filled in by hand, signed on paperv1

Eye exam intake

Health information for your eye exam. Answer what you know — nothing here is a diagnosis. The consent wording is a starting point, not legal advice: adapt it to your province, your insurer and your professional order.

Client name

Phone

When was your last eye exam? *

Do you wear *

  • Glasses
  • Contact lenses
  • Neither

Any of these lately?

  • Blurry vision
  • Headaches
  • Dry or itchy eyes
  • Flashes or floaters
  • Double vision
  • None

Known eye conditions, in you or your family (glaucoma, cataracts, macular degeneration)

Do you have diabetes? *

  • Yes
  • No

Current medications

I consent to the clinic collecting the health information above for my eye examination and keeping it as part of my record, as a regulated health professional is required to. I may ask to see or correct it at any time.

I have read and agree to the statement above.

Signature

Printed name

Date

This form is a starting point, not legal advice. Have it reviewed for your province or state before use.

What the PDF looks likeLetter · 8.5 × 11 in

Business name

optometrists
v1

Intake and consent form

Client name
Phone

When was your last eye exam? *

Do you wear *

  • Glasses
  • Contact lenses
  • Neither

Any of these lately?

  • Blurry vision
  • Headaches
  • Dry or itchy eyes
  • Flashes or floaters
  • Double vision
  • None

Known eye conditions, in you or your family (glaucoma, cataracts, macular degeneration)

Do you have diabetes? *

  • Yes
  • No

Current medications

I consent to the clinic collecting the health information above for my eye examination and keeping it as part of my record, as a regulated health professional is required to. I may ask to see or correct it at any time.

I have read and agree to the statement above.

Signature
Printed name
Date
Free form from clevrstart · clevrstart.compage 1 of 1

See the booking for optometrists · Letter, 8.5 × 11 in, one page.