New Patient Registration Form | Dr. Jeff Sciberras

New Patient Registration Form

Dr. Jeff Sciberras - Optometrist
Name *

First Name Last Name
Date of Birth *

Month Day 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
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? *
Should be Empty: