Clarity Eye - CODEC - Prequalifying Questionnaire

Initial Screening

Complete these initial questions to determine if you're a suitable candidate. Should your results deem you eligible for assessment, you'll be directed to the next step: intake form and photo submission.

Question 1.
Do you experience frequent or ongoing eye irritation?
Yes
No
Question 2.
Have you previously received dry eye treatment?
Yes
No
Question 3.
Do you continue to experience symptoms after trying conventional dry eye treatments, such as artificial tears?
Yes
No

Initial Screening

You have completed the initial screening for CODEC. Based on your responses, we have determined that:

You’ve passed the screening questions.

You can now proceed to step 2 of your application.

Before we can schedule your in-person assessment, you are required to complete the intake form. Please ensure you provide all requested information.

Initial Screening

You have completed the initial screening for CODEC. Based on your responses, we have determined that:

You do not qualify for this service at this time.

You do not meet the requirements for CODEC at this time.

We recommend you continue to monitor your symptoms and if they worsen, please contact our program at dryeyes@clarityeye.ca.

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You're almost there!

To complete the assessment of your dry eyes, we require further information from you. Please complete the intake form below to complete your intake submission.

Intake Form

* Mandatory

Full Name*

Date of Birth*

Email Address*

It is your responsibility to make sure that your email address is entered correctly, as it is the primary means for our communication with you including plans for surgery.

Confirm Email Address*

Phone Number*

Preferred CODEC location*

Which symptoms are you experiencing?* Burning or stingingRednessGrittinessWatery eyesBlurred or changing visionSensitivity to lightContact lens discomfortEyelid irritationOther

How long have you experienced these symptoms? *

Do your symptoms affect one or both eyes?* Right eyeLeft eyeBoth eyes

Do you currently wear contact lenses?* YesNo

List any eye drops, ointments or eye medications you currently use.*

Have you received dry eye treatment in the past?* YesNo

If yes, please describe the treatments you have received.*

Have you previously had eye surgery?* YesNo

Please provide any other information that may help our team review your request. *

Providing optometrist and family doctor information allows us to keep your healthcare team aware of your diagnoses and surgery.

Optometrist name (if you have one)

Optometrist fax number

Family doctor name (if you have one)

Family doctor fax number

I consent to be assessed for CODEC through Clarity Eye Institute. I acknowledge that I have read and agree to the disclaimer terms below:

You are agreeing to the following:

I understand that this form is intended for non-urgent CODEC self-referral requests. Submitting this form does not provide a diagnosis, confirm an appointment or guarantee that a specific test or treatment will be recommended.
I consent to being contacted by Clarity Eye about my submission. I understand that additional information may be requested before an appointment is arranged.
CODEC uses email for communication. Any time email is used, private health information shared can be compromised. I accept this risk and understand that I can seek further information about privacy from the CODEC team.
It is my personal responsibility to arrange an optometrist or family doctor appointment if CODEC recommends this based on my application.

Signature*

Date Signed*

You have successfully completed your intake form for CODEC.

Your information will be reviewed and you will receive an email response within one (1) week. There are two possible responses you could receive:

If you are confirmed to be a candidate, we will be in touch to offer you appointment dates. Appointment dates are scheduled within 1 month from time of approval.
If you are not a candidate, we will recommend that you seek a referral from your optometrist or family doctor, as you may require further assessment beyond what is offered through CODEC.

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Core Eye Services

CODEC self-referral

Initial Screening

Question 1.

Do you experience frequent or ongoing eye irritation?

Question 2.

Have you previously received dry eye treatment?

Question 3.

Do you continue to experience symptoms after trying conventional dry eye treatments, such as artificial tears?

Initial Screening

Initial Screening

You're almost there!

Intake Form

You have successfully completed your intake form for CODEC.