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Your Vision Is Our Focus

We are located at 189 Huron Street in Stratford, ON

Call 519-271-2020

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Hours & Location
Our Eye Care Clinic
Eye Care Services
Eyeglasses
Contact Lenses
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EnChroma Color Blind Test

Hours & Location
Our Eye Care Clinic
Eye Care Services
Eyeglasses
Contact Lenses
Insurance
EnChroma Color Blind Test

Home » Connect With Us » Appointment Request Form

Appointment Request Form

Name*
First Last
Phone*
Email*
Date
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Reason for Appointment
Please provide a reason for your appointment. Details are stored securely and not sent by email.
Preferred Date & Times*
Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.
Best Time to be Reached for Confirmation*

: Hours

Minutes

AM/PM
Are you covered under any Ontario funding?*
- Are you covered under any Ontario funding?
- Indigenous Status
- ODSP (Ontario Disability Support Program)
- None
- Other
Patient Type : If you are a new patient please fill out New Patient Form*
- Returning patient
- New Patient
Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Cell Phone
Daytime Phone
Email Address
Please provide us your email address.
Availibility*
Please provide 3 days of availability
What can we help you with?*
Are you covered under any Ontario funding?*
- Ontario Works
- Indigenous Status
- ODSP (Ontario Disability Support Program)
- None
- Other
Personal Information
Employment Status
Employment Status - Other
Please provide your employment status.
Employer
Occupation
How were you referred to our office?
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
Eye History
Please check off any current conditions you suffer from
- I stopped wearing glasses
- I stopped wearing contact lenses
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
I stopped wearing contact lenses because:
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:
Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
List brands you wear
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all medications
Please list all drug allergies you have
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Health Card Number*
Version Code*
If you have coverage through another plan/organization, please fill in the details below.
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Phone
This field is for validation purposes and should be left unchanged.

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Stratford Family Eye Care

189 Huron St.
Stratford, ON N5A 5S9

Phone: 519-271-2020
Fax: 519-271-5287
Email: reception@stratfordfamilyeyecare.ca
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 8:00 PM
Thursday: 8:00 AM - 8:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Open most Saturdays 9am-2pm, please call ahead
Sunday: Closed

* Closed long weekends.

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Stratford Family Eye Care
189 Huron St.
Stratford, ON N5A 5S9
Phone: 519-271-2020
https://www.stratfordfamilyeyecare.ca

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