New Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address*

Please provide us your email address.

Personal Information

Gender*

Female
Male

Date of Birth*

Health Card Number (OHIP) including last 2 letters

Occupation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

Please check off any current conditions you suffer from

I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

How often do you replace or dispose your contact lenses?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

Please check off all that apply to you

I am having problems with my current contact lenses
My eyes feel dry
I am interested in refractive laser surgery

Medical History

When, approximately, was your last eye exam?

Who is your primary care physician?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Do you take any drops for your eyes?

Please list all drug allergies you have

Please bring all insurance cards with you to your appointment.

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

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Name

This field is for validation purposes and should be left unchanged.