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Glenmore Landing Vision Center » Request An Appointment

Request an Appointment

For the best possible care of your eyes, book an appointment with one of our optometrists!

Patient's General Information
Just some general information about the patient
Patient's Name*
Prefix First* Last*
Date of Birth*
DD slash MM slash YYYY
Actual Age
Cell Phone Number*
Home Phone Number
Parent/Legal Gurdian Name*
First Last
We need either parent or legal guardian name for all of our patients whose age is up to 16 years
Patient Type*
- New Patient
- Returning Patient
Alberta Health Care Number
Email*
By having your email we can notify you when you are due for your next examination, as well as inform you of any special office information & promotions. You can expect an email roughly every 2 months. Your email address is never shared.
How did you hear about us?*
- Facebook
- Yellow Pages
- Friends or Family
- Post Mail Out
- Knows the Doctor
- Internet Search
- Walked By (Signage)
- Referred by Doctor (MD)
- Other
Please name them so we can thank them*
Please Mention Your Other Source*
Appointment Information
Please provide some basic information about which time do you want to set up the appointment
Preferred Date*
MM slash DD slash YYYY
Preferred Time of Day*
Reason for Your Visit*
Do you want to fill out your Medical Information Form online?*
- Yes, of course
- No, will do it in the office

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Medical Information
Has there been a change to your medical, optical, or family history? If so... please tell us here!
When was your last eye exam?*
By whom?*
Reason for your visit?*
Do you have glasses?*
- Yes
- No
How old are they?*
Do you wear contact lenses?*
- Yes
- No
How often do you wear them?*
- Full time (sleep in them)
- Full time (removing nightly)
- 3-5 days/week
- 1-3 days/week
- Other
Please mention, how often do you wear your contact lense*
How old are they?*
How often do you replace them?*
Are you happy with the vision & comfort in your contacts?*
- Yes
- No
Are you needing to refill your contact lens supply?*
- Yes
- No
Please explain, why you do not feel comfortable*
What is the brand name of the current contacts you wear?*
Please read & complete this section if you DO NOT wear contact lenses.
Contact lenses are a great compliment to wearing eyeglasses. Not only do some people prefer to wear contacts because of cosmetic appearance, but also because there are many situations where freedom from glasses is benecial. Contact lenses oer the exibility to perform dierent activities with more ease and comfort (such as swimming, sports, golf, etc).
Contact lenses are now being made better then ever. They now come in convenient daily wear designs (wear once & discard) which provides superior eye health and comfort. They also now correct many dierent types of vision problems. Besides being a great choice for correcting distance vision, there are now new contact lens designs available (multifocal contacts) that can correct reading issues as well.
Are you interested in wearing contact lenses and scheduling a consultation or fitting?*
- Yes
- No
Do you have any of the following health problems?*
- Diabetes
- High blood pressure
- Arthritis
- Thyroid
- Heart Problem
- None
If you have other health problems or concerns, mention them here
What pills / medications are you taking?*
If you are not taking anything, then put "None" in the box
Have you had any injuries or surgery to your eyes?*
If you did not have any injuries or surgery to your eyes, put "None" in the box
What allergies do you have?*
If you do not have any allergies, then put "None" in the box
Is there a family history of?*
- Cataracts
- Glaucoma
- Macular Degeneration
- None
If there is any other family medical history, please mention
Do you feel that learning milestones are being met?*

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Lifestyle Questions
To help us make accurate eye wear recommendations, please provide us with the following information
Grade*
Occupation*
Hobbies*
Do you play sports? Which one?*
If you do not like sports, type "None"
How much time do you spend in the sun?*
Computer use, how many hours per day?*
Do read in the sun? How many hours per day?*
If you don't read in the sun, type "None"
Any other interests?
Do you have sunglasses?*
- Yes
- No
Extra Testing
Please read the details below thoroughly before making any decission
Please Read: An important part of any eye examination is checking the health of the eyes. To better assist the doctor in assessing the interior health of your eyes, we are please to inform you that our office is equipped with state of the art diagnostic equipment. These instruments will provide your doctor with an ultrasound type of scan of your retina (back of the eye), digital photo of the retina, as well as a screening of your peripheral vision (test to detects vision loss & defects).
By using these two special instruments together, your doctor can better detect certain medical problems, such as; brain tumours, strokes, macular degeneration, glaucoma, blood vessel problems, optic nerve problems, etc. Beginning stages of some of these conditions are only detectable by having these special scans & photographs taken. Early detection enables your doctor to provide care and treatment to help preserve your health and vision years sooner then previously possible. Your results and images from the extra testing, will be reviewed with you today, by your doctor. All information gathered will stay on file, and will serve as baseline to compare to in future exams and help assess any future changes to your vision and the health of your eyes.
Alberta Health Care only covers the cost of a basic routine visit. If you would like to have this valuable extra testing done today, the fee will be $55.00*
- I choose to have the extra testing today & I agree to pay the $55.00 fee.
- I choose to decline the extra testing.
Healthy Retinal Scan

Scan of Unhealthy Retina (Macular Degeneration)
Healthy Retinal Photo

Photo of Unhealthy Retina (Macular Degeneration)
Extra Testing
Please read the details below thoroughly before making any decission
Please Read: An important part of any eye examination is checking the health of the eyes. To better assist the doctor in assessing the interior health of your eyes, we are please to inform you that our office is equipped with state of the art diagnostic equipment. These instruments will provide your doctor with an ultrasound type of scan of your retina (back of the eye), digital photo of the retina, as well as a screening of your peripheral vision (test to detects vision loss & defects).
By using these two special instruments together, your doctor can better detect certain medical problems, such as; brain tumours, strokes, macular degeneration, glaucoma, blood vessel problems, optic nerve problems, etc. Beginning stages of some of these conditions are only detectable by having these special scans & photographs taken. Early detection enables your doctor to provide care and treatment to help preserve your health and vision years sooner then previously possible. Your results and images from the extra testing, will be reviewed with you today, by your doctor. All information gathered will stay on file, and will serve as baseline to compare to in future exams and help assess any future changes to your vision and the health of your eyes.
Alberta Health Care only covers the cost of a basic routine visit. If you would like to have this valuable extra testing done today, the fee will be $55.00*
- I choose to have the extra testing today & I agree to pay the $55.00 fee.
- I choose to decline the extra testing.
Healthy Retinal Scan

Scan of Unhealthy Retina (Macular Degeneration)
Healthy Retinal Photo

Photo of Unhealthy Retina (Macular Degeneration)
Name
This field is for validation purposes and should be left unchanged.

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Our Doctors

Dr. Nielson
Dr. Prasad
Dr. Larocque
Dr. Craig

Hours of Operation

Monday, Wednesday, Fridays: 9:00 AM to 5:30 PM
Tuesday: 7:45 AM to 5:30 PM
Thursday: 8:00 AM to 8:30 PM
Saturdays: 9:00 AM to 2:00 PM

Our Location

Glenmore Landing
D168 1600 90 Ave.,
SW Calgary, T2V5A8

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