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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email Date of birth Date Format: DD slash MM slash YYYY DD/MM/YYYYFamily Doctor First Last Health Card #Format 10 digits and 2 letters (####-###-###-AA)Health Card Expiry Date Date Format: DD slash MM slash YYYY DD/MM/YYYYOccupationHow 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? Date Format: DD slash MM slash YYYY DD/MM/YYYYDo you wear contact lenses?YesNoHave 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 medicalCAPTCHA