Visual Needs, Ocular, and Medical History.
NOTE: This form is for those who have an appointment booked with us
Information you will need to have before you start:
Health Card Number
Information about your own eye and health history
Information about your family’s eye history
NOTICE OF COLLECTION OF PERSONAL INFORMATION AND CONSENT TO COLLECT
“We” and “our” mean the following optometric practice: COMLY EYE CARE
READ CAREFULLY BEFORE SUBMITTING: By sending this form, you consent to our collection of the information above.
We collect, use and share your personal information for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibility for benefits and/or services; to arrange payment for services; and as required by law.
The collection of this information is authorized by the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Health Protection and Promotion Act.
We will take all reasonable steps to ensure that your personal information is treated confidentially and is only used for the purposes it was collected. We will take all reasonable steps to prevent unauthorized access, use or disclosure of your personal information.
You may obtain access to your personal information stored by us in accordance with the Personal Health Information Protection Act by making a written request to: info@comlyeyecare.ca
More information about our collection, handling and protection of personal information is available in our privacy policy, located here: Privacy Policies
If you would like to make a comment or complaint regarding the collection, use, disclosure or handling of your personal information you may contact: info@comlyeyecare.ca
You also have the right to complain to the Information Privacy Commissioner / Ontario, 1400-2 Bloor Street East, Toronto, ON M4W 1A8 (800-387-0073) Thank you for your cooperation