Download Refraction Patient Acknowledgement Form

Refraction Patient Acknowledgement Form
This form will be retained by your optician and added to your patient health record. A copy of this form
will be provided by your optician to the College of Opticians of Ontario for statistical purposes. The
information that you provide will be held in the strictest confidence.
A. Patient Information—to be completed by the patient
Family Name
First Name
Date of Birth (yyyy/mm/dd)
Apartment Number
Middle Name
Home Telephone Number
Work Telephone Number
Street Name and Number
City
Province
Postal Code
Occupation
B. Patient History—to be completed by the patient
Have you ever had a complete
eye exam?
Yes
No

Do you wear corrective
lenses?
Yes
No



Is this your first time receiving a
refraction from an optician?
Yes
No


Do you recall the date of that
exam?
Yes
No


Date of last complete eye
exam:
Year
Month Day
C. Contraindications to Refraction (where No is checked for any of the following)—to be
completed by the optician in conjunction with the patient
No
The patient’s personal health
history is clear of diabetes?
Yes
Yes
No

The patient has a history of being
cataract-free:
Yes

The patient’s personal health
history is clear of glaucoma:
Yes
No

The patient has a history of being
free from age-related macular
degeneration:
Yes
The patient’s personal health
history is clear of strabismus?
Yes
No
Yes


The patient’s visual acuity is
correctable to 20/40 in each eye:
Patient is over 19 and under 65
years of age:
Yes
Preliminary evaluation suggests
good eye health:







No

No

No

No

If this review indicates a No to any of the above questions, then the patient MUST be
immediately referred to a physician or optometrist for a complete eye exam.
This form is two (2) pages and requires that you complete BOTH pages.
Version 2.0
Page 1 of 2
This consultation is solely intended to determine your suitability to receive
a refraction for the purpose of obtaining corrective lenses by a registered
optician. Please be reminded that refraction does not diagnose the health
of your eye.
A copy of this form will be provided to the College of Opticians of Ontario (COO), where
the information contained herein will be used by the COO purely for statistical purposes.
The COO understands the importance of protecting personal information, and as such
all information listed will be treated by the COO in strict confidence.
Signature of patient or guardian: __________________
Date: ___________________
Signature of optician: __________________C#:_______ Date: ___________________
This form is two (2) pages and requires that you complete BOTH pages.
Version 1.0
Page 2 of 2