Patient Contact 2020 - COPY

Welcome to Our Secure Patient Messaging Portal

Please note: This form is for only for Prism patients only.
Submissions that are not from Prism patients will not be processed.

PATIENT PRIVACY

We take your safety and privacy very seriously.
Before filling out your request, you are required to read and accept our Terms of Use and Privacy Policies.
Read the Terms of Use and Privacy Policies
By clicking the NEXT button, you acknowledge that you have read and accept our Terms of Use and Privacy Policies.
Otherwise please close this form now.

This form is compliant with Canada’s Personal Information Protection and Electronic Documents Act (PIPEDA).

PATIENT INFORMATION

Please note that staff review incoming messages daily Monday to Friday from 8:00am to 5:00pm. Incoming messages are NOT reviewed on Saturdays, Sundays or statutory holidays.

Messages about an eye health concern that are deemed urgent based on medical criteria will be sent to your doctor for response to you within 24hours. Non-urgent eye messages about eye health concerns will be sent to your doctor within 24 hours and will be responded to within 4 days. If your condition worsens, or you feel that you require medical attention before receiving a response, go to a hospital emergency department for an assessment.

PLEASE FILL IN ALL FIELDS BELOW

Name*

First Name

Last Name

Digital Consent*

Yes, I consent to receive digital communications from Prism.

(Note: You must consent in order to use this service)

Email Address*

You must provide an email address

Phone (Please provide preferred contact number)**

Health Card Number and Version Code*

Ontario Health Card Other Provinces No Provincial Health Numbers

Health Card (10 digit number)*

Must be 10 digits

Health Card Version Code (2 letters after 10 digit number)*

Click here to see where to find your health card information

Birthdate*

Address*

Address Line 1

City

Province

Postal Code

Prism Doctor

Please select your Prism doctor:*

If you do NOT have an optometrist and wish to see one at Prism, please click HERE

Please Note: You must have had an appointment with your Prism doctor within the past 14 months to be considered a current patient of Prism.

If you have not see your Prism doctor within the past 14 months this form will not be processed.
Please see your optometrist or family doctor if you require care.

Please select one of the following options:*

I have a question or want to change an upcoming appointment I have questions or concerns about an upcoming surgery. I have a concern about my eye health. I want to request a refill on my prescription. Other

Optometrist Inquiry Form

You have selected one of our Optometrists. Please enter your request for an appointment or question/inquiries below.*

Unknown Doctor Inquiry Form

Please enter your questions/inquiries below. Our staff will check your file and confirm your Prism doctor.*

Upcoming Appointment Inquiry Form

Please enter your questions/inquiries about your upcoming appointment below for our staff to review.*

Upcoming Surgery Inquiry Form

Please enter your questions/inquiries about your upcoming surgery below for our staff to review.*

General Inquiry Form

Please enter your questions/inquiries below for our staff to review.*

Request for Prescription Renewal

Please list the medication(s) you would like refilled.*

Have you begun taking any additional prescription medications since your last appointment with your Prism doctor? If yes, please provide specific details.*

Have there been any changes to your eye health since your last appointment with your Prism doctor? If yes, please provide specific details.*

Have there been any changes to your general health since your last appointment with your Prism doctor? If yes, please provide specific details.*

Please provide the name and address of your Pharmacy.

You can use the search bar in Google Maps to find the address of your Pharmacy.
Click here for Google Maps

Pharmacy Name *

Pharmacy Address*