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Please Complete Intake and Consent Form Below for COVID Purposes

    Pre-Examination Form:

    13. May we use email or SMS to communicate with you?*

    Our office often uses email or SMS to communicate with patients. This information may be confidential and personal in nature. Although we are very careful on our end to keep these emails confidential, you should know that email/SMS messages in general are not encrypted and may exist indefinitely. Level of security is dependent on the e-mail/SMS client or app you use. We cannot guarantee the security of e-mails or SMS messages sent outside of the clinic. The clinic cannot guarantee that your email/SMS will be received, read or responded to within any particular period of time. The main advantage of email/SMS communication is convenience, particularly when scheduling appointments, answering questions, information about our clinic, and receiving timely information regarding your orders, care and examination results.

    FOR MEDICAL EMERGENCIES or other time-sensitive matters, we DO NOT recommend to communicate with the clinic via email/SMS. Please try calling your local hospital, our clinic or even 911 for any emergencies.

    14. I prefer this form of communication:*

    Pre-Examination Consent & Information:

    WHAT IS INCLUDED IN A FULL EYE EXAM?

    A full eye exam is $95 and includes a vision and eye health assessment. The optometrist will ensure you are seeing to the best of your ability and assess your eye health from the outside in. Specialized imaging of your eye structures may be added at an additional cost of $40-$70. You will leave your appointment with a prescription for eyeglasses if required. Please address your main concerns with the optometrist during your visit so we can best serve you.

    WHAT IS NOT INCLUDED IN A FULL EYE EXAM?

    A full eye examination does not include any consultation regarding contact lenses, eye surgeries, vision therapy, myopia control or other specialized topics. If you are interested in any of these things, please do mention it to your optometrist! Your optometrist can then discuss with you whether or not additional fees apply for your requirements. Please note that we do not provide any measurements or consultation related to purchasing eyeglasses or contact lenses online.

    WHAT IS EYE DILATION?

    Eye dilation may be recommended by your Optometrist. Dilation eye drops open your pupils so that the optometrist can look inside your eyes and view important structures including your retina and optic nerve. Dilation eye drops can make your vision light sensitive and blurry for a duration of 2 hours or more. Driving may be difficult until the effect of the drops wear off, so please prepare necessary provisions for your transportation. If you wish to decline this testing or reschedule it for another day, please let your Optometrist know.

    FOR CONTACT LENS WEARERS OR THOSE INTERESTED IN CONTACT LENSES:

    In order to obtain a contact lens prescription the optometrist will have to test your eyes with the contact lenses on. A Contact Lens Examination can cost anywhere from $50 to $120 depending on your contact lens requirements. When you do a contact lens exam and purchase your contact lenses with us, you are protected by our contact lens warranty and are guaranteed the best price with our online price match policy!

    Please note that your visit for a FULL COMPREHENSIVE EYE EXAM can take 30-60 minutes or more depending on your specific needs. Depending on the testing you require and our efforts to maintain a safe and clean environment for our patients, wait times before and during your appointment may range from 15-30 minutes. Since every patient's visual and eye health needs are unique, more or less time may be required during an exam to address all of our patient's specific concerns. Eye exams will begin with pretesting and ocular history before seeing the Optometrist. If your visit is time sensitive, please inform our staff upon your arrival as well as the Optometrist during your eye exam so we can better cater to your needs. Thank you in advance for your patience!

    16. Have you read and understand all of the aforementioned information?*

    COVID-19 Precautions:

    At Dr. Archie Chung & Associates Optometrists we are doing everything we can to keep our patients, team and doctors safe. For more information about everything we are doing to combat the spread of COVID-19 while we continue caring for our patients, click here: https://www.chungandtseeyecare.com/en/covid19-update. Any time you are in a public place, there is a chance that you may be exposed to COVID-19. Despite the protective measures we have taken, by attending an appointment at our clinic, you are accepting this risk. Please acknowledge the following:

    I hereby acknowledge that by booking an appointment at Dr. Archie Chung & Associates Optometrists, I am aware of the following:

    1. There is a risk that I could be exposed to COVID-19 while attending my appointment at Dr. Archie Chung & Associates Optometrists. I accept and acknowledge that I could be exposed to COVID-19 through the following means and acknowledge that this list is not exhaustive:

    a) My physical presence at Dr. Archie Chung & Associates Optometrists
    b) My interactions with other patients or members of the public who are present at the time of my attendance
    c) My interactions with team, agents and other health care professionals
    d) The physical touching of any equipment, objects or fixtures

    2. While receiving services, our team, optometric assistants or Optometrist may need to be physically closer to me than the recommended social distancing guidelines in order to assess and/or treat me.

    17. Do you acknowledge, accept and confirm the above conditions for your visit?*

    18. a) Do you have any of the following new or worsening symptoms or signs?*

    • Fever or chills

    • Decrease or loss of taste or smell

    • Cough

    • Nausea, vomiting or diarrhea

    • Trouble breathing

    • Pink eye

    • Sore throat or trouble swallowing

    • Headache

    • Runny or stuffy nose

    • Very tired, sore muscles or joints

    Note: If you have an existing health condition that gives you the symptoms, select “No,” unless the symptom is new, different or getting worse. If mild headache, tiredness, sore muscles or joints occur within 48 hours after getting a COVID-19 vaccine, select “No” and continue to follow all public health measures. If symptoms last longer than 48 hours or worsen, select “Yes”.

    18. b) Does anyone in your household have one or more of the above symptoms and/or are waiting for test results after experiencing symptoms?*

    Note: If you are fully vaccinated, select “No.” Fully vaccinated is defined as an individual who has received their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series 14 days ago or more.

    Note: If the household member’s mild headache, tiredness, sore muscles or joints occurred within 48 hours after getting a COVID-19 vaccine, select “No”. If their symptoms last longer than 48 hours or worsen, select “Yes.”

    18. c) Have you been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate? If you are fully vaccinated and have not been advised to self-isolate by public health, select “No.”*

    18. d) In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.”*

    18. e) In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*

    19. I understand that I am required to wear a mask or nose and mouth covering to my appointment and that I am not to remove my mask under any circumstances within the clinic without instruction from the Optometrist. Please note that we do not allow masks with exhalation valves or other open-air systems within our health care setting. If I arrive at my appointment without an appropriate mask or nose and mouth covering, I will be required to purchase a surgical mask at the clinic for $2.00.*

    Insurance Direct Billing:

    This form must be filled out when insurance claims are submitted electronically by Dr. Archie Chung & Associates Optometrists at Woodbine Mall (Woodbine Mall, 500 Rexdale Blvd., Unit D014,Rexdale, ON M9W 6K5) on the patient’s behalf and retained for two years in the patient file following closure of the patient file.

    Insurance Benefit Assignment:

    28. I hereby assign benefits payable for the eligible claims to the healthcare provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to such provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the healthcare provider for any services rendered and/or supplies provided.

    I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this benefit assignment form, that any benefit payment made in accordance with this benefit assignment form will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

    I understand that this assignment will apply to all eligible claims submitted electronically by my healthcare provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the healthcare provider.*

    Insurance Electronic Transmission Authorization and Consent Form:

    Personal information that we collect and disclose about you, and if applicable, is used by the insurer, and/or plan administrator of your group benefits plan, its affiliates and their service provider(s) for the purposes of assessing eligibility for your claims, underwriting, investigating, auditing and otherwise administering the group benefits plan, including the investigation of fraud and/or plan abuse and for internal data management and data analytical purposes.

    29. I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize such insurer and / or plan administrator and their service provider(s) to: use my personal information for the above purposes, exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits, or other benefits programs, other organizations, or service providers working with such insurer and/or plan administrator or any of the foregoing, when relevant for the above purposes, and where applicable exchange personal information concerning any claims with any assignee of benefits payable and exchange personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law. I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my employer or benefit plan sponsor, for the purposes of investigation and prevention of fraud and/or benefit plan abuse. I understand that the submission of fraudulent claims is a criminal offence. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my benefit plan sponsor, for that purpose. If the patient is a person other than myself, I confirm that the patient has given their consent to provide their personal information for the healthcare provider and the insurer and/or plan administrator and their service provider(s) to use and disclose their personal information as set out above.*

    COVID-19 Precautions:

    At Dr. Archie Chung & Associates Optometrists we are doing everything we can to keep our patients, team and doctors safe. For more information about everything we are doing to combat the spread of COVID-19 while we continue caring for our patients, click here: https://www.chungandtseeyecare.com/en/covid19-update. Any time you are in a public place, there is a chance that you may be exposed to COVID-19. Despite the protective measures we have taken, by attending an appointment at our clinic, you are accepting this risk. Please acknowledge the following:

    I hereby acknowledge that by booking an appointment at Dr. Archie Chung & Associates Optometrists, I am aware of the following:

    1. There is a risk that I could be exposed to COVID-19 while attending my appointment at Dr. Archie Chung & Associates Optometrists. I accept and acknowledge that I could be exposed to COVID-19 through the following means and acknowledge that this list is not exhaustive:

    a) My physical presence at Dr. Archie Chung & Associates Optometrists
    b) My interactions with other patients or members of the public who are present at the time of my attendance
    c) My interactions with team, agents and other health care professionals
    d) The physical touching of any equipment, objects or fixtures

    2. While receiving services, our team, optometric assistants or Optometrist may need to be physically closer to me than the recommended social distancing guidelines in order to assess and/or treat me.

    32. Do you acknowledge, accept and confirm the above conditions for your visit?*

    33. a) Do you have any of the following new or worsening symptoms or signs?*

    • Fever or chills

    • Decrease or loss of taste or smell

    • Cough

    • Nausea, vomiting or diarrhea

    • Trouble breathing

    • Pink eye

    • Sore throat or trouble swallowing

    • Headache

    • Runny or stuffy nose

    • Very tired, sore muscles or joints

    Note: If you have an existing health condition that gives you the symptoms, select “No,” unless the symptom is new, different or getting worse. If mild headache, tiredness, sore muscles or joints occur within 48 hours after getting a COVID-19 vaccine, select “No” and continue to follow all public health measures. If symptoms last longer than 48 hours or worsen, select “Yes”.

    33. b) Does anyone in your household have one or more of the above symptoms and/or are waiting for test results after experiencing symptoms?*

    Note: If you are fully vaccinated, select “No.” Fully vaccinated is defined as an individual who has received their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series 14 days ago or more.

    Note: If the household member’s mild headache, tiredness, sore muscles or joints occurred within 48 hours after getting a COVID-19 vaccine, select “No”. If their symptoms last longer than 48 hours or worsen, select “Yes.”

    33. c) Have you been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate? If you are fully vaccinated and have not been advised to self-isolate by public health, select “No.”*

    33. d) In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.”*

    33. e) In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*

    34. I understand that I am required to wear a mask or nose and mouth covering to my appointment and that I am not to remove my mask under any circumstances within the clinic without instruction from the Optometrist. Please note that we do not allow masks with exhalation valves or other open-air systems within our health care setting. If I arrive at my appointment without an appropriate mask or nose and mouth covering, I will be required to purchase a surgical mask at the clinic for $2.00.*

    Experiencing Technical Difficulties? Please do not worry!

    If you can not complete our new online intake and consent form for Covid-19 purposes because you’re currently experiencing any technical difficulties, please do not worry! Please inform our clinic of any challenges. We can also do the screening and assist you directly in clinic if you arrive a bit earlier before your appointment. We are always striving to improve. If you have any questions or concerns, please contact us at woodbine@chungandtseeyecare.com. Thank you.

    Please remember to ensure your browser is up to date, clear browser cache and cookies and turn off any adblocker browser extensions to see if that resolves any technical difficulties.