Request For e-Assessment

A SECURE METHOD FOR SHARING INFORMATION
  • Personal Information

    Please fill out all information below.
    To see where to find your health card number click here

    (Note: You must consent in order to use this service)
  • Must be 9 digits
  • Date Format: MM slash DD slash YYYY
  • (Please provide preferred contact number)
  • Eye Health Information

    If no information is available please enter NA.

  • (Please provide as much detail as possible)
  • (What is your current eye health concern?)
  • Health History

    Please provide as much detail for each question. If no information is available please enter NA.

  • Image Upload

    Please take close up pictures of both eyes with the flash ON.
    For instructions on taking the pictures click here.

  • Drop files here or
  • Acuity Test

    To assist us with your e-assessment, we recommend you do a quick online vision test HERE and when complete enter your numbers below.