Langley Optometry Clinic


Pre-Examination Form

We are proud to offer a full range of vision services and products. This sheet helps us help you!
Please print this form,fill in the information required and bring it with you to your visit. You may also E-mail this information to us by filling in the required fields and pressing the "SEND" button at the end of this form.
Thank you.

Information

First name:

Last name:

Phone number:

Full Address:

Postal code:

Age:

BC health care card number:

Date of birth:

Occupation:

Gender:
Male Female

Are you a previous patient at Langley Optometry Clinic? YES NO

When was your last eye exam?

If you have already booked an eye examination appointment at our clinic, please indicate the date of your eye exam:

If you have NOT already booked an appointment for an eye examination with us, please indicate in the boxes bellow up to three tentative dates that are convenient for you to come in for your eye exam. We will contact you to book your appointment as soon as possible.




Your Vision

We want to know as much as possible about your vision interests and needs, so your Doctor can recommend the best options for you. Please check items you would like to discuss with us.

Vision and Eye Health

Laser surgery Crossed eyes UV exposure Lazy eye Low vision Diabetes & Vision

Other:

Eyewear and Lens Options

Contact lenses Glasses Sun Protection Sport Vision
Disposable Driving Polarized Swimming
Colored Computer UV Protection Skiing
Daily disposable Reading Clip-ons Hockey
Part-Time Wear Progressives Tinting Tennis
Continuous Wear Safety Wear Transition Soccer
Rigid Lenses Thin Lenses Golf Cycling
Multifocals Glare Free Fishing Jogging

Prescription History

Please list all medications that you are currently taking including vitamins in the box bellow.

Prescription medications and vitamins:


Thank You for completing this form. We look forward to seeing you at your next visit!