Covid Waiver

Name*

Email*

Please select Primary Insurance Company*

Please select Secondary Insurance Company*

*** Please note it is important to complete this insurance information to prepare for your appointment as not all insurance plans allow direct billing and we do not accept all insurance plans

My Health Card Number is*

My Version Code is*

*** Please note OHIP covers one exam per year for 19 years and younger and aged 65 and older. B y providing your health card number we can make sure you are eligible to avoid extra exam fees

Have you had a cough or fever in the last 14 days?*

Yes
No

Have you been in contact with a person who has tested positive for COVID in the last 14 days?*

Yes
No

I understand that:

I am required to give 24 hours notice for an appointment cancellation to avoid a missed appointment fee*

Yes
No

Until a vaccine is developed we are using retinal imaging technology that allows us to check the back of the eye without coming in close contact with the patient. This service is not covered by OHIP and there is a $35 fee. Non Ohip exams have this service automatically included as always and there is no change to the fee structure*

Yes
No

When I arrive I will park out front of the office and call the phone number posted on the door 905-853-3452. Once we have your exam room sterilized we will come and get you from your car and take you right in.

If you have any additional information that you would like to share with us before your exam please let us know:*

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