Patient file Transfer Form

If you would like us to gather your eye care information from your previous eye doctor. Please fill in this information.

As this form is being used electronically, we cannot release a copy of these files to you, until you have an eye examination in our clinic. We will require government-issued photo-ID to verify your identity.

Please note that these forms are not 100% secure. As such, we try to limit the amount of identifiable information. Do not include your Alberta Health Care number, if we require it, we will call you.

Name

First Name

Last Name

Date of Birth

YYYY

Cell Phone Number

Previous Clinic Name or Doctors Name

Include as much information as possible to make it easier for us to locate your last doctor.

I authorize Helio Optometry to Contact the Above Clinic to Release the following Information.

Eyeglass Prescription

Contact Lens Prescription

Last Complete Eye Exam

Last Medical Eye Exam

Message

Please type in any additional concerns you may have or information that might make this request easier.

Digital Signature

Write your complete name as a digital signature.

Patient file Transfer Form

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Ph: 780.628.6855

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