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PATIENT HEALTH SCREENING FORM
*
Indicates required field
1. Are you experiencing or have any of the following?
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Discharge
Redness
Irritation (foreign body sensation)
Pain
Double vision, Surgery, or Trauma (within last 30 days)
One Seeing Eye
Prescription Eye Drop Refills Needed
None
If you have any of the above symptoms, please consult your on-site doctor. If a referral is needed, feel free to call us, and we’ll gladly connect you with a trusted specialist.
2. Patients with the following conditions will require management that may delay the finalization of a corrective RX until the condition is stable or referral is fulfilled:
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Glaucoma or optic nerve disease
Retinal diseases including Macular Degeneration and Diabetic Retinopathy
Uncontrolled Diabetes
Keratoconus or other corneal diseases
Cataracts at certain stages
Contact Lens Fittings that may require in-person care.
None
3. Are you or your insurance paying for your eye exam?
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Yes
No. MSP is paying.
We cannot claim to MSP (health card) yet.
As of now, we are unable to bill MSP (health card). If your eye exam is covered by MSP, please consult with your on-site doctor. If a referral is needed, feel free to call us, and we’ll gladly connect you with a trusted specialist.
4. Do you need an eye exam for ICBC Driver Medical Examination?
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Yes
No
5. Are you aware of that the eye exam site is at 2752 Rupert Street location?
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Yes
No
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Home
ABOUT US
Advanced Eye Exam
Deals
ONLINE CATALOG
Reviews
Contact
