New Patient Registration Form | Dr. Jeff Sciberras

Registration Form

Dr. Jeff Sciberras
* Denotes Mandatory Field
Name*

FirstLast
Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther
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

CityProvince

Postal Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Preferred Contact

PhoneEmailText
Family Doctor
What type of vision correction do you use?*

GlassesContact LensesNone
What is the purpose of your visit?*

Routine CheckupNeed Contact LensesNeed GlassesFlashing Lights / FloatersSudden Vision LossHeadachesRed EyesDry EyesOther
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?*

YesNo
Please list the health conditions that you are being treated or monitored for.
Medications
Have you had eye surgery?*

YesNo
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?*

YesNo
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?*

DoctorInternetFamilyFriend
Their name (optional)
Policy #: Contact your insurance provider to determine your coverage.
I give permission to Dr. Sciberras' staff to make direct claims to my insurance provider for services / products provided.

YesNo
Should be Empty: