Please use this link on your smart phone to complete the Visual Acuity Testing questions below:
Visual Acuity Testing Online
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Are You A New Patient?
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No
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Appointment Information
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Additional Questions
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To answer the below Acuity Results questions, please complete this visual online vision test (above) on your smart phone to assist us with your patient assessment.
Right Eye Acuity Results
Left Eye Acuity Results
OHIP Number - Include VC
Physician/Optometrist name
Physician Email
Physician Phone Number
Family doctor name
Family Doctor phone number
What is your current eye health concern? Please provide as much detail as possible
Which eye is affected?
Left
Right
Both
Do you have any loss of vision?
None
Mild
Moderate
Severe
Do you have any eye pain?
None
Mild
Moderate
Severe
Are your eyes red?
Yes
No
Do you wear contact lenses
Yes
No
Are you diabetic?
Yes
No
What previous eye conditions or procedures have you had?
Please list your current eye drops.
What other general medical conditions do you have?
Please list your current medications (pills)
Please type any other questions here:
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