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Patient Intake Form

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?

Thanks for submitting!

info@westcoastophthalmology.com

Phone: (250) 334-4030

Fax: (250) 338-8155

We respectfully acknowledge that the land we gather on is on the Unceded traditional territory of the K’ómoks First Nation, the traditional keepers of this land.

©2023 by Dr. S. W. Shaver Inc.

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