How can we help you?

What is your goal for this eye exam?

• Prevention and confirmation that everything is fine
• I have recently experienced discomfort and want to act before it gets worse
• An eye exam was requested for another process (work, studies, etc.)
• I received a diagnosis some time ago and did not follow up
• An eye condition was detected and I want a second opinion
• Other (briefly specify)
  Please briefly describe the situation:

Which vision problem are you hoping to correct with surgery?

• I would like to stop wearing glasses (myopia, astigmatism, etc.)
• I cannot see clearly and want a lasting solution
• I think I have cataracts
• I have been diagnosed with glaucoma or another chronic condition
• I am not sure which surgery I need and want an evaluation
• Other (briefly specify)
  Please briefly describe the situation:

Do you already have a diagnosis or was this surgery previously recommended?

• Yes, it was recommended during another consultation (specify whether at UOC or elsewhere)
• No, I am exploring my options
• I have recent test results that I would like reviewed
• I do not have any tests yet

Which symptom or situation best describes what you are experiencing?

• My eyes often feel dry, irritated or burning
• Blurred vision or difficulty focusing or seeing at a distance
• Eye pain, pressure or frequent discomfort
• My eyes are red or watery most of the time
• Difficulty reading, using screens or driving at night
• I have a previous diagnosis and need follow-up care
• An eye condition was detected and I want a second opinion
• Other (briefly specify)
  Please briefly describe the situation:

Which diagnostic study do you need?

• Dry eye study
• Tomography or fundus examination
• Visual field test
• Eye pressure measurement
• Other (specify the prescribed study)
  Please briefly describe the situation:

Which diagnostic study do you need?

• Dry eye study
• Tomography or fundus examination
• Visual field test
• Eye pressure measurement
• Other (specify the prescribed study)
  Please briefly describe the situation:

Send us a photo of the medical order, if available:

Why do you want to change your glasses now?

• I no longer see well with my current glasses
• I want a more comfortable or stylish frame
• My glasses are broken or in poor condition
• My current glasses make me dizzy or make it difficult to focus
• Other (briefly specify)
  Please briefly describe the situation:

Do you have a recent prescription?

• Less than 6 months ago
• Between 6 months and 1 year ago
• More than 1 year ago

What prompted you to schedule this eye exam?

• I want to schedule their first eye exam
• I want to schedule a follow-up eye exam
• The child has difficulty reading, writing or concentrating in class
• The child complains of headaches, fatigue or blurred vision
• Glasses were prescribed and I want a second opinion
• Other (briefly specify)
  Please briefly describe the situation:

What prompted you to schedule this eye exam?

• They have difficulty seeing clearly
• They complain of cloudy or blurred vision
• They have recently fallen or stumbled
• Cataract surgery was recommended, but they are not convinced
• Other (briefly specify)
  Please briefly describe the situation:

Does your family member have a pre-existing health condition?

• Yes, diabetes
• Yes, hypertension
• Yes, both
• No known condition
• I am not sure
• Other (please specify):
  Please briefly describe the situation: