Patient Name: (required)

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Patient's Availability: (required)

Referred by: (required)

MD / Nurse Practitioner OHIP Billing (if applicable)

Reason for Referral (Select All that Apply)
Diabetic Eye ExaminationReduce VA / Blurred VisionEye Pain / DiscomfortRed Eye / Infection / AllergiesHeadacheDiplopiaEpiphoraPhotopsia / FloatersGlaucoma / Family History of GlaucomaCataracts / Family History of CataractsGeneral Eye ExaminationOther (write in notes)

Please Select Location: (required)
Ajax Location: Kodak Lens Harwood Eyecare (314 Harwood Ave. S. in Harwood Plaza)Etobicoke Location: Kodak Lens Cloverdale Eyecare (250 The East Mall in Cloverdale Mall)North York Location: Kodak Lens Centerpoint Eyecare (6464 Yonge St. in Centerpoint Mall)Rexdale Location: Kodak Lens Woodbine Eyecare (500 Rexdale Blvd. in Woodbine Centre Mall)Riverdale Location: Kodak Lens Broadview Eyecare (318 Broadview Ave. South of Gerrard)Scarborough Location: Kodak Lens Parkway Eyecare (85 Ellesmere Rd. in Parkway Mall)Toronto Location: Kodak Lens Toronto Eyecare (364 Yonge St. North of Dundas)

Notes: