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 InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Daytime PhoneCell PhoneEmail AddressPlease provide us your email address.Do you wish to receive email communications from our office?*YesNoPersonal InformationGender*FemaleMaleDate of Birth* Health Card NumberOccupationHow were you referred to our office?Select Referral Type >Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherReferral Status - OtherPlease let us know how you were referred to our office.If you were referred by a patient, whom may we thank? First Last Communication PreferenceSelect Communication Preference >EmailCell PhoneDaytime PhoneEye HistoryFrequent Headaches/Migraines : new?YesNoLaser Eye Surgery- if no, any interest?YesNoEye Surgery : Please listDouble Vision/Eye Turn: new?YesNoSudden Loss of VisionYesNoIf yes, when?Floaters: new?YesNoFlashes: new?YesNoDate of last dilated retinal exam: Glasses HistoryDo you wear glasses?*YesNoWhat glasses do you own? Single Vision Bifocals Safety Glasses Backup Glasses Progressive Trifocals Sports Glasses Sunglasses Other 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 value between 0 and 24.Contact Lens HistoryDo you wear contact lenses?*YesNoWhat brand of contact lenses do you wear?How old are your current lenses?How often do you replace or dispose your contact lenses?What brand of solution do you soak your lenses in?What is your typical wearing schedule? In hours per day:Please enter a value between 0 and 24.What is your typical wearing schedule? In days per week:Please enter a value between 0 and 7.Please check off all that apply to you I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in changing or enhancing my eye color I am interested in a non-surgical method of vision correction I am interested in refractive laser surgery I don't have a spare set of contact lenses My spare contact lenses have an incorrect prescription Medical HistoryWhen, approximately, was your last eye exam?Where did you get your last eye exam?When, approximately, was your last physical exam?Who is your primary care physician?Do you drink alcohol?SelectNoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayDo you smoke?SelectNoYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per dayPlease 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 medical or eye conditions that run in your family (biological first degree relatives: ie. mom/dad/siblings) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)Please list all hospital surgeries you have ever had:Please list all prescription and over-the-counter medications you take and for what conditionsPlease list all drug allergies you havePrimary InsurancePlease bring all insurance cards with you to your appointment.Insurance Company NameInsurance Company Phone NumberAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Insured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Patient's Relation to InsuredSecondary InsuranceDo you have secondary insurance?YesNoIf you have coverage through another plan/organization, please fill in the details below.Insurance Company NameInsurance Company Phone NumberAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Insured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Patient's Relation to InsuredCommentsIf you have any comments you would like to add, please enter them here.EmailThis field is for validation purposes and should be left unchanged.