New Patient Registration Form
Dr. Jeff Sciberras - Optometrist
Name
*
First Name
Last Name
Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
*
Gender
*
Male
Female
OHIP Number
Input if patient is under age of 20 or over age of 65
OHIP Number
Input if patient is under age of 20 or over age of 65
Home Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Preferred Contact
Phone
Email
Text
Family Doctor
What type of vision correction do you use?
*
Glasses
Contact Lenses
None
What is the purpose of your visit?
*
Routine Checkup
Need Contact Lenses
Need Glasses
Sore / Red Eyes
Flashing Lights / Floaters
Sudden Vision Loss
Headaches
Other
Have you had eye surgery?
Yes
No
Have you experienced: fever, cough, difficulty breathing/swallowing, loss of taste/smell, runny/congested nose, muscle aches, GI problems, been in contact with someone with COVID-19 or have travelled outside Canada in the 2 weeks before your exam date?
Yes
No
Occupation
Medications
Allergies
How did you hear about us?
*
Doctor Referral
Internet
Family / Friend
Referral
Existing Patient
Do you have private insurance?
*
Yes
No
Insurance / Provider #: (Contact your insurance provider before your visit to determine your coverage.)
What is the date and time of your eye exam with us?
*
Submit
Should be Empty: