Kindly fill the form below to book the appointment now.

Or you can print this form, fill it and bring it during your visit.

[[[["field12","equal_to","Other"]],[["show_fields","field15"]],"and"],[[["field41","equal_to","Scarborough Site"]],[["show_fields","field44"]],"and"],[[["field41","equal_to","Vaughan Site"]],[["show_fields","field45"]],"and"],[[["field41","equal_to","Brampton Site"]],[["show_fields","field46"]],"and"]]
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Clarity Eye Institute

Welcome to Clarity Eye. This form must be completed and signed before you may receive care in our clinic. No information contained in your medical record will be sold to a third party for any purposes. Every effort will be made to see patients in a timely order. We thank you for your patience.

PLEASE HAND IN YOUR HEALTHCARD WITH THIS FORM.

First Name
Last Name
Address:
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Unit
City
Postal Code:
Tel: Daytime:
Alternate:
Do you wish to receive correspondence and information from Clarity by email?
Date of Birth
Sex:
Health Card
Version Code
Referring Doctor:
Family Doctor
Please circle any/all that apply to your health
Other
Medications: (attach List)
Upload
Are you taking Blood Thinners?
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Allergies:
Previous Surgeries:
Patient Signature:
Date

OR

Guardian/Interpreter Name:
Signature:

Workers Compensation Claim. Please complete if injury is work related.

SIN#
Date Of Accident
Employer's Name
Address
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Disclaimer

Ophthalmologists accept new patients by medical referral only. Please ensure your doctor has forwarded the referral prior to contacting the office to assist with scheduling appointments at Clarity.

Working with the surgery team for the updated patient resources that we have on our current website so they too can be printed or filled on line and submitted to clarityeye.surgery@gmail.com