Patient Registration Welcome! Please help us serve you by filling out this form and submitting it to our office. We look forward to assisting you! About YouName* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email Date of birth DD slash MM slash YYYY DD/MM/YYYYFamily Doctor First Last Health Card # Format 10 digits and 2 letters (####-###-###-AA)Health Card Expiry Date DD slash MM slash YYYY DD/MM/YYYYOccupation How did you find out about us?FamilyFriendGoogle SearchFacebookInstagramOtherOcular HistoryWhat is the purpose of your visit? (click all that apply) Annual visit Blurry Vision Burning Double vision Dryness Flash of light Floaters or Spots in vision Headaches Infection Itchiness Night vision difficulty Eye pain Tearing Grittiness Additional comments about the purpose of your visit (optional)When was your last eye exam? DD slash MM slash YYYY DD/MM/YYYYDo you wear contact lenses? Yes No Have YOU been diagnosed with any of the following? (Click all that apply) Cataracts Corneal abrasion Dry eye Eye turn Glaucoma Injury Keratoconus Iritis/uveitis Lazy eye Macular degeneration Retinal defect/tear/hole Retinal detachment Other eye diseases Additional comments about your previous history (optional)Has anyone in your FAMILY been diagnosed with any of the following? (Click all that apply) Cataracts Corneal abrasion Dry eye Eye turn Glaucoma Injury Keratoconus Iritis/uveitis Lazy eye Macular degeneration Retinal defect/tear/hole Retinal detachment Other eye diseases Medical HistoryHave you ever been diagnosed or treated for any of the following health problems? (Click all that apply) Diabetes High blood pressure Arthritis Asthma Cancer Headaches Respitory Stroke Additional comments about your previous history (optional)Current medicationsPlease include hormones, Birth control, and non-prescription medicationsAllergiesPlease include food, seasonal, and medicalPhoneThis field is for validation purposes and should be left unchanged.