Patient Registration

About You

Name*

First Last

Address

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

Phone*

Email

Date of birth

DD/MM/YYYY

Family Doctor

First Last

Health Card #

Format 10 digits and 2 letters (####-###-###-AA)

Health Card Expiry Date

DD/MM/YYYY

Occupation

How did you find out about us?

What is the purpose of your visit? (click all that apply)

Additional comments about the purpose of your visit (optional)

When was your last eye exam?

DD/MM/YYYY

Do you wear contact lenses?

Have YOU been diagnosed with any of the following? (Click all that apply)

Additional comments about your previous history (optional)

Has anyone in your FAMILY been diagnosed with any of the following? (Click all that apply)

Have you ever been diagnosed or treated for any of the following health problems? (Click all that apply)

Additional comments about your previous history (optional)

Current medications

Please include hormones, Birth control, and non-prescription medications

Allergies

Please include food, seasonal, and medical

Name

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