New Patient Registration Form | Dr. Jeff Sciberras

Registration Form

Dr. Jeff Sciberras
* Denotes Mandatory Field
Name *

First Last
Date of Birth *

Month Day Year
Gender *

Male Female Other
OHIP Number
Input if you are under the age of 20 or 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

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 Flashing Lights / Floaters Sudden Vision Loss Headaches Red Eyes Dry Eyes Other
Please provide details about the purpose of your visit.
What year was your last eye exam? *
Are you being treated or monitored for any health conditions? *

Yes No
Please list the health conditions that you are being treated or monitored for.
Medications
Have you had eye surgery? *

Yes No
Please provide details about the eye surgery or surgeries you have had in the past.
Do you use prescribed or over the counter eye drops? *

Yes No
Please list the prescription or over the counter eye drops that you use, and please bring them to your visit.

Have you been diagnosed with: *

How did you hear about us? *

Doctor Internet Family Friend
Their name (optional)
Policy #: Contact your insurance provider to determine your coverage.
I give permission to the service provider to make direct claims on my behalf.

Yes No
Should be Empty: