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Medical History and Needs Form

  • Due to COVID-19, our office procedures have been enhanced for your safety. To ensure a safe and efficient visit for you, we require that you complete and submit this Medical History and Needs Form in the next 48 hours to guarantee your appointment. Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide your email address.
  • MM slash DD slash YYYY
  • Covid -19 Questionnaire

  • Fee Consent- this only applies for those covered by OHIP for their eye exam

  • OHIP covers the basic elements of an eye examination. Dr Kingstone uses advance diagnostic testing not covered by OHIP (Digital retinal imaging and Ocular Coherence Tomography (OCT)) to detect and manage retinal eye disease earlier and more precisely, resulting in better health outcomes. It is highly recommended that all patients take advantage of these procedures in addition to their regular eye exam. Please note: this only applies to those who are covered for their regular eye exam through OHIP
  • Medical History

  • Include Name of Medication, Dosage, Frequency Taken
  • Family History

    Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.

    Do you currently or have you ever had any problems in the following areas?
  • Neurological

  • Eyes

  • Respiratory

  • Vascular/Cardiovascular

  • Bones/Joints/Muscles

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.