New Patient - Wink Eyecare

Welcome to Wink

Are you a new patient? Welcome to Wink and thank you for choosing us for your eyecare needs.

Please fill out the form below so that we can prepare your file in advance of your arrival.

We look forward to your first visit to our office.

Welcome to Wink! Please fill out this new patient form so that we can open a file before your arrival. Thanks in advance. We look forward to taking good care of you!

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

Please specify if home or cell phone number

Date of Birth

MM

DD

YYYY

Day / Time of your Appointment

Leave blank if unknown

Concerns

Please feel free to specify any concerns you may have

Consent

I consent to Wink contacting me by phone, email or text as needed. I understand that Wink is committed to protecting my privacy but cannot guarantee the confidentiality of information sent by email/text as communication sent via webmail services such as Gmail may be stored/routed outside of Canada.

What to Expect

Please take a moment to review what to expect at your first visit at Wink.

Not feeling well?

If you are unwell, please:

Delay your visit and notify us by phone at 905 849 8897 or email info@winkeyecare.ca
Contact one of the following for further instructions:
- Your doctor
- Telehealth Ontario 1 866 797 000
- Dial 311 or Halton Region Public Health 905 825 6000
For additional resources, please consult Halton Region Public Health

Thank you for helping us keep our office safe for all.

Best,
Your Wink Eyecare Team