Patient Intake Form Welcome to Tonic Eye Care & Vision Therapy Please read the information below and fill out the form at the bottom of the page. WHAT IS INCLUDED IN A COMPREHENSIVE EYE EXAMINATION The cost of a comprehensive eye examination is $125 and includes a full vision and eye health assessment. An examination will take approximately 45-60 minutes. Your optometrist will assess your eye health and ensure you are seeing to the best of your ability. Eye examinations include retinal photos (also known as fundus photos or imaging) that capture a digital image of the back of your eyes that includes the retina, blood vessels, optic nerve, and macula, helping the early detection and management of ocular diseases. Your examination may be covered by OHIP if you are a minor younger than 19-years-old or a senior older than 65-years-old and have not received an eye examination in the past 12 months. If you are an individual between the ages of 20-years-old and 64-years-old and have a certain systemic (such as diabetes) or ocular condition (such as retinal problems), you may also be covered. Please check with one of our staff for your eligibility. Your eye examination requires eye dilation to complete a comprehensive assessment of your eye health, unless recommended otherwise. Dilation eye drops enlarge your pupils, allowing your optometrist to view important eye structures. Dilation will make you sensitive to light and cause blurry vision, especially at near, for a duration of 2-5 hours. As driving may be difficult during this time, please make the necessary arrangements for your transportation. Eye examinations include a prescription for glasses, if required. Please note that we do not provide any measurements or consultation regarding the purchase of glasses online. If you have any other specific concerns, please raise them with your optometrist during your examination. Eye examinations covered under OHIP do not include any specialized imaging (retinal photos) or the additional specialty services mentioned below. WHAT IS NOT INCLUDED IN A COMPREHENSIVE EYE EXAMINATION The eye examination does not include consultation regarding contact lenses, laser eye surgery co-management, vision therapy, or other specialized areas. If you are interested in any of these, please indicate below and mention it to your optometrist. Your optometrist can provide more information regarding these topics, and whether any additional fees apply. CONTACT LENS CONSULTATIONS AND FITTINGS In order to prescribe contact lenses, your optometrist will have to conduct a Contact Lens Fitting to test different lenses and how they fit and feel on your eyes. A Contact Lens Fitting costs between $50 to $100 depending on the types of lenses and your experience wearing them. For more information, please consult your optometrist. Note that any contact lenses purchased from Tonic Eye Care & Vision Therapy are covered under our contact lens warranty policy. COVID-19 PROTOCOLS Due to COVID-19, we have additional policies and procedures in place. All patients over the age of 2 are required to bring their own mask that covers their nose and mouth. Expect to keep the mask on for the entirety of your appointment and time spent inside the clinic. All patients should limit the number of people accompanying them. Patients should come alone if possible, but can be accompanied by one other person if necessary. Full details of our COVID-19 policies can be found here. Consent to Collect and Exchange Personal Information PURPOSE Personal information that we collect and disclose about you, and if applicable, is used by the insurer, and/or plan administrator of your group benefits plan, its affiliates and their service provider(s) for the purposes of assessing eligibility for your claims, underwriting, investigating, auditing and otherwise administering the group benefits plan, including the investigation of fraud and/or plan abuse and for internal data management and data analytical purposes. AUTHORIZATION AND CONSENT BY CHECKING THE AUTHORIZATION AND CONSENT BOX BELOW, YOU AGREE TO THE FOLLOWING TERMS: I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize such insurer and/or plan administrator and their service provider(s) to: Use my personal information for the above purposes. Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits, or other benefits programs, other organizations, or service providers working with such insurer and/or plan administrator or any of the foregoing, when relevant for the above purposes. Where applicable, exchange personal information concerning any claims with any assignee of benefits payable and exchange personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law. I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my employer or benefit plan sponsor, for the purposes of investigation and prevention of fraud and/or benefit plan abuse. I understand that the submission of fraudulent claims is a criminal offence. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my benefit plan sponsor, for that purpose. If the patient is a person other than myself, I confirm that the patient has given their consent to provide their personal information for the healthcare provider and the insurer and/or plan administrator and their service provider(s) to use and disclose their personal information as set out above. BENEFIT ASSIGNMENT I hereby assign benefits payable for the eligible claims to the healthcare provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to such provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the healthcare provider for any services rendered and/ or supplies provided. I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this benefit assignment form, that any benefit payment made in accordance with this benefit assignment form will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this assignment will apply to all eligible claims submitted electronically by my healthcare provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the healthcare provider. All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal. PATIENT INFORMATION First Name Last Name Guardian First Name (if Patient is under 18) Guardian Last Name (if Patient is under 18) Full Address Postal Code Date of Birth (YYYY-MM-DD) Email Phone Number Preferred Communication EmailPhoneSMS GP / Family Doctor Name GP / Family Doctor Phone Number How Did You Hear About Us? GoogleInstagram/FacebookReferral/Word of MouthInsurance ProviderOther INSURANCE DIRECT BILLING AUTHORIZATION AND CONSENT Primary Insurance Provider --Select Insurance Provider--Blue CrossBPA GroupCanada LifeCanadian Construction Workers Union (CCWU)Chambers of Commerce Group InsuranceCINUPClaimSecureCowanDesjardinsEmpire LifeEquitable LifeFirst CanadianGMS Carriers 49 and 50Green ShieldGroupHEALTHGroupSourceIndian AffairsIndustrial AllianceJohnson InsuranceJohnston Group Inc.LiUNA Local 183LiUNA Local 506ManionManulife FinancialMaximum BenefitNexgenRxOntario Disability Support Program (ODSP)Ontario Teachers Insurance Plan (OTIP)Ontario Works (OW)RCMPSSQ InsuranceSun LifeThe Co-operatorsVeterans Affairs Canada (VAC)WSIB Other (Write In) Plan Number (include all spaces and dashes) Certificate/Plan Member Number (include all spaces and dashes) Insured Member Yes No N/A Insured Member Name (If Not Insured Member) Relationship With Insured Member (If Not Insured Member) ADDITIONAL SERVICES Please indicate below if you are interested in any of the following additional services: Prescription eyeglasses Sunglasses (with or without prescription) Contact lens consultations and fittings Myopia control Vision therapy Post concussion vision rehabilitation LASIK or other corrective laser eye surgery co-managements AUTHORIZATION AND CONSENT I have read and understood all the above information related to my appointment and eye examination. I consent to the collection, use, and disclosure of my personal health information as entered above in accordance with PHIPA. I authorize my healthcare provider, insurer, and/or plan administrator to collect, use, and disclose personal information concerning any benefit claims submitted on my behalf. I accept the related terms and conditions as described in the below Consent to Collect and Exchange Personal Information. I consent to receive communication by email including those related to appointment scheduling, billing, orders, promotions, and newsletters. SUBMIT INTAKE FORM For all patients, please also click here to submit a COVID-19 Questionnaire prior to your appointment.