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your Kingstone optometrist

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Eye care for adult & children

We direct bill most insurance companies

Cataraqui Town Centre: 945 Gardiners Road ,Kingston,K7M7H4

Fax +1 613-900-4371

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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 :

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:

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)

© 2020 by Wellvision inc

Tel: 613-689-9439

Fax +1 613-900-4371

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