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Underhill Optometry Consent Form for OHIP Patients

  • OHIP covers the basic elements of an eye examination. Underhill Optometry uses advance diagnostic testing not covered by OHIP to detect and manage eye disease earlier and more precisely, resulting in better health outcomes.
  • I hereby consent to:
    • Accepting payment receipts and optical prescriptions via email
    • Providing my personal health information to ensure the time I spend in the office is efficient and focused on my medical care
    • Being automatically charged a fee of $60 if I do not attend my appointment or cancel with fewer than 48 hours’ notice.

    “We” and “our” mean the following optometric practice: Underhill Optometry

    READ CAREFULLY BEFORE SIGNING: By signing this form, you consent to our collection of the information above

    We collect, use and share your personal information for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibility for benefits and/or services; to arrange payment for services; and as required by law.

    The collection of this information is authorized by the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Health Protection and Promotion Act.

    We will take all reasonable steps to ensure that your personal information is treated confidentially and is only used for the purposes it was collected.  We will take all reasonable steps to prevent unauthorized access, use or disclosure of your personal information.

    You may obtain access to your personal information stored by us in accordance with the Personal Health Information Protection Act by making a written request to Underhill Optometry

    More information about your collection, handling and protection of personal information is available in our privacy policy, posted online at

    If you would like to make a comment or complaint regarding the collection, use, or disclosure or handling of your personal information you may contact: Gillian Pengelly, or 416-445-7490.

    You also have the right to complaint to the Information Privacy Commissioner/Ontario, 1400-2 Bloor Street East, Toronto, ON M4W 1A8 (800-387-0073)

    I have read the information on this form and DO consent to the above.
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