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 InformationPatient Name* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone Number*Please provide a telephone number, with area code, so we can contact you.Email Address*Please provide us your email address.Family Doctor/clinic:Alberta Health Care #:New patient only - How did you find us?Occupation:Last Eye Exam:*Vision/Ocular History & Concerns: Blurred Vision > 2 hours of screen use daily Light sensitivity Tired eyes Difficulty with night driving Double Vision Glaucoma/Family History Macular Degeneration/FHx Other OtherDry Eye Symptoms: Tearing/Watering Burning/Itchiness Gritty/Scratching Sensation Pressure Behind eye Sharp Pain Redness Contact Lenses: Renew Prescription First time Wearer Bifocal Contact lenses Coloured Contact Lenses Medical History: Diabetes Headaches/Migraines High Blood Pressure Arthritis Thyroid Cancer HIV Colitis/Crohns Other OtherDo you Smoke?* Yes No Are you Pregnant?* Yes No Medications:*Allergies:*Surgeries:*Primary InsuranceInsurance Company NameInsured Name (as on Card) First Last Insured Date of Birth MM slash DD slash YYYY Patient Relation to InsuredGroup NumberPolicy NumberSecondary InsuranceDo you have secondary insurance? Yes No Insurance Company NameInsured Name (as on card) First Last Insured Date of Birth MM slash DD slash YYYY Patient Relation to InsuredPolicy NumberGroup NumberCommentsIf you have any comments you would like to add, please enter them here.CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
