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your Kingstone optometrist

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Eye care for adult & children

We direct bill most insurance companies

Kingston :Cataraqui Town Centre: 945 Gardiners Road

Fax +1 613-900-4371

Mississauga : 3420 Hurontatio street ,Mississauga

Fax +1 905-798-5044

Book@ Mississauga

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Yes, I would like my eyes dilated today if the doctor believes it is necessary.

No, I do NOT want my eyes dilated (see below).

REASON OF THE VISIT : * Required

Routine Eye Exam

Contact Lenses Fitting

Dry Eye

Vision Problem

Glasses

Other

Do you have Any OF:

Glaucoma

Diabetes

Macular Denegeration

See Flashes

See Floaters

Double vision

Headach

Do you Have Any Family History

Glaucoma

Macular Degeneration

Other Eye Diseases

None

Don't know

Is there Past History OF: * Required

Eye Injures

Eye Surgeries

Color Blindness

None

Do You have Any Allery ?

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Cataraqui Town Centre: 945 Gardiners Road ,Kingston,K7M7H4 (next to Lenscrafters)

Tel: 613-817-8545

Fax +1 613-900-4371

© 2020 by Wellvision inc

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