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WHITBY VISION CARE

  • 736 Dundas Street West
    Whitby, Ont. L1N2N4
    905.666.4848
    www.whitbyvision.ca

    DR. PAMELA SCHMTZ
    DR. LINDA SUJO
    DR. PAMELA ANDREWS
    DR. KETHARINI SIVASEGARAN

    We ask that you kindly complete all the information below. This information will greatly aid in the assessment of your vision and ocular health.

    I understand that my personal information is kept strictly confidential and used for the sole purpose of my examination. I also understand that I am mailed a recall notice to remind me of any future visits.
  • MM slash DD slash YYYY
  • YesNo
    Glasses
    Contact lenses
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • SelfFamily
    Age Related Macular Degeneration (AMD)
    Glaucoma
    Cataracts
    Blindness
    Crossed/Lazy eye
    Retinal Detachment
    Heart Problems
    Stroke
    High Cholesterol
    High Blood Pressure
    Smoker
    Arthritis
    Thyroid Disease
    HIV/Hepatitis
    Cancer
    Neurological Problems
    Diabetes
    Kidney Trouble
  • WE THANK YOU FOR COMPLETING THIS FORM