Intake Form

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First Name *

Last Name *

Phone *

Date of birth *

Email *

Address *

City *

Province / Territory *

Postal Code *

Family member Name (If booking for eye exam)

Date of Birth

Relation

Insurance Company Name *

Coverage $

Primary Holder Name (if Different)

Date of Birth

Contract/Group/Plan/Policy#

Member/Certificate/ID #

UCI # (IFHP Coverage)

OHIP Number (if under 19 or over 65 years old)

Secondary Insurance Name (If available)

Coverage $

Primary Holder Name (if Different)

Date of Birth

Contract/Group/Plan/Policy#

Member/Certificate/ID#

How did you hear about us?

* 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 purpose of billing and coverage. 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. I certify information provided is true and correct.

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