Name: Clayton Heights Optometry
Address: 19151 Fraser Hwy Suite 103A, Surrey, BC, V3S 8E7, CA
Telephone: 604-372-4030
Price range: $000 - $300

Name*

First Last

DOB

Gender at Birth:

Male
Female

Pronoun preference:

Gender Identity:

Non-Binary
Male
Female

Name of Spouse/Emergency Contact*

Health ID #

Phone*

Occupation

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Fever

Self

Family

Type

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Smoker?

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How long

Alcohol

Drinks per day

Recreational Drugs

Allergies

Head Injury/Concussion?

Family Doctor/GP

Contact Lenses?

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Do you use Eye Drops

Type of Eye Drops

Medications

Patient Intake (Adult)

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Clayton Heights Optometry