• Eye Clinic Patient Registration Form

  • Sex*
  • Date of Birth*
     - -
  • Did you provide care or have close contact with a person with COVID-19 without wearing the appropriate PPE?*
  • Do you have any of the following new or worsening symptoms or signs?
  • Do you need new eye glasses?*
  • Are you are a contact lens wearer?*
  • Are you a "New" or "existing" patient?*
  • (HIDE)Current Date
     - -

  • Health Card Information

    (if you don't have OHIP card now, just input anynumber and letter, choose random date. but you should bring your Health Card to the Clinic at the time of appointment)

  • Date*
     - -
  • Format: (000) 000-0000.
  • Mobile (cell phone)?*
  • Format: (000) 000-0000.
  • Mobile (cell phone)?
  • Name of your Family Doctor
  • Name of previous Optometrist
  • Last Eye Exam
     - -

  • Insurance information

    For this time, we are trying to minimize the visiting time at the office and we are not processing direct billing to your insurance company. We are truly sorry for the inconvenience.

  • Pre-Test information

    The information you provide in this section is important and will help your doctor to diagnose your eye condition. Please enter as much information as you can.

  • Rows
  • I consent to Eye Clinic Center to contact me regarding my medical reports, and education regarding my vision/ocular health using the contact information I have provided for personal communication.*
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