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DR. SALABA
Our Specialties
DR. PAUL
NEWS
Book Online
Home
ABOUT
COLLECTIONS
GALLERIES
EVENTS
Optometrists
DR. SALABA
Our Specialties
DR. PAUL
REVIEWS
JOBS
Shop Eyeglasses & Contact Lenses. Book an Eye Exam Optometrists from Hamilton, Ontario.
Let's get to know each other.
Name
*
Name
First Name
Last Name
Email Address
*
Date of Birth
Date of Birth
MM
DD
YYYY
Address
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone
Primary Phone
(###)
###
####
Secondary Phone
Secondary Phone
(###)
###
####
Preferred Method of Contact
*
Tell us the best way to reach you.
Email
Phone
Employment Information
*
Our eyes are also working! Please tell us what you do for work.
Job Description
*
Please describe your job duties to us.
Family Doctor
If you do not currently have a Family Doctor, let us know.
Family Doctor Phone Number
Family Doctor Phone Number
(###)
###
####
Insurance Information
*
Do you have insurance?
Yes
No
I am unaware of my insurance information.
Plan Name
Policy #
Group #
Do you have dependant coverage?
Yes
No
Have you ever been treated for...
*
We will keep track of your medical history.
Cancer
Asthma
Sinusitis
Diabetes
Anemia
Epilepsy
Chronic Obstructive
Blood Pressure
Heart Trouble
Joint Problems
Tuberculosis
A.I.D.S.
Pulmonary Disease
Thyroid Disorders
Eye Trouble
Kidney Disease
Gall Bladder
Cardiovascular Disease
N/A
Emergency Contact
*
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
*
Emergency Contact Phone Number
(###)
###
####
Emergency Contact Email
Purpose of your visit with us.
*
Check all that apply.
First Eye Exam
Annual Eye Exam
Child’s Eye Exam
Trunk Show
Contact Lenses
Glasses
Macular Degeneration
Cataracts
Red Eye
Diabetes
Glaucoma
Floater
Other
How did you hear about us?
*
We want to know!
Facebook page
Twitter
Website Blog
Internet Search (Google, Yahoo...)
Website Appointment
Phone Call
Walk In
Facebook Ad Campaign
Direct Mail
Friend
Family
ReferralOption One
Option Two
Do you wear the following?
*
Check all that apply.
Prescription Glasses
Prescription Sunglasses
Non-Prescription Sunglasses
Contact Lenses
I don't wear any of these.
What do you use all of the time?
Your answers to these questions will guide us in recommending the best products to meet your eyewear needs.
My prescription glasses.
My prescription sunglasses.
My contact lenses.
For Reading/Working:
My prescription glasses.
My prescription sunglasses.
My contact lenses.
For Driving:
My prescription glasses.
My prescription sunglasses.
My contact lenses.
For Sports or Outdoor Recreation:
My prescription glasses.
My prescription sunglasses.
My contact lenses.
Which do you do regularly?
Check all that apply.
Night Driving
Work Outdoors
Commute 20+ min. By Car
Work w/ Small Objects
Work Under Fluorescent Light
Read For Long Periods
Work on a Computer
Travel on Airplanes
Watch TV for 3+ hrs/Day
Work at a Desk
Frequently Alternate Between Indoors & Outdoors
Hobbies/Recreation:
Spend time at the cottage in the summer? Read a lot by the water? Spend time sewing or golfing? Maybe you are on tour with your band? We would love to know how YOU keep busy!
What do you like about your current glasses?
What is important when choosing your new glasses?
Please check all that apply.
Image
Frame Material
Fit
Durability
Weight
Brand
Fashion Trends
Lens Type
Lens Thickness
Frame Colour
Lens Colour
Can we stay in touch?
*
At Advanced Vision, we take pride in building authentic relationships to provide a customized experience that meets your needs. In order to serve you better, we are asking for your approval to build a relationship with you via email and share the following information with you: Trunk Shows – Events that feature exclusive new and upcoming brands Promotions – Exclusive friend’s and family opportunities to save If you wish to receive this information and consent to us sending you this information by email or other forms of electronic communication, please check the box below. It is our promise to you that we will not abuse this privilege.
Yes!
No thank you.
PLEASE BRING THE FOLLOWING TO YOUR EXAM:
YOUR CURRENT GLASSES & SUNGLASSES. A LIST OF CURRENT MEDICATIONS.
It’s so nice to meet you!