*Final*Eastgate Eye Clinic Patient Registration Form

Eye Clinic Patient Registration Form
Patient Name*
Last NameMiddle NameFirst Name
Sex*
MaleFemale
Date of Birth*
MonthDayYear
Date
Home Address*
Street Address
Street Address Line 2
CityProvince
Postal CodeCountry
Did you provide care or have close contact with a person with COVID-19 without wearing the appropriate PPE?*
YesNo
Do you have any of the following new or worsening symptoms or signs?
FeverHeadacheChillsNew or worsening coughShortness of breathRunny nose, sneezing, nasal congestionSore throatHoarse voiceDifficulty swallowingNew smell or taste disorder(s)Nausea/vomiting, diarrhea, abdominal pain Unexplained fatigue/malaise
Do you need new eye glasses?*
YesNo
Are you are a contact lens wearer?*
YesNo
Are you a "New" or "existing" patient?*
NewExisting
(HIDE)Calculation
(HIDE)Current Date
MonthDayYear
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)
OHIP Number*
Version Code*
Date*
MonthDayYear
Date
Primary Phone Number*
Mobile (cell phone)?*
YesNo
Alternative Phone Number
Mobile (cell phone)?
YesNo
Email*
example@example.com
Name of Parent (or Guardian)
Occupation
How did you hear about us?
Name of your Family Doctor
I don't knowI don't have oneDr.
Name of previous Optometrist
I don't knowI don't have oneDr.
Last Eye Exam
MonthDayYear
Date doesn't need to be accurate
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.
What is the main reason for this appointment ?*
e.g. routine eye exam, vision loss, Contact Lenses related
If you have any symptom(s) related to your eye condition, please provide details.*
(type N/A if not applicable)

Please check below if you have any of following condition(s)

	Yes
Blurry Vision "when I need to see Near"	1
Blurry Vision "when I need to see Far"	2
Blurry Vision "when I wear glasses"	3
Blurry Vision "when I DO NOT wear glasses"	4
Diplopia(Double Visions)	5
Flashes	6
Floaters	7

Do you have any headaches? If so, what type of headache? when and how often do you get them?*
(type N/A if you do not have any, e.g. migraine, cluster )
Have you had any injuries or accidents happen to you in the past? *
(type N/A if you do not have any )
Have you had any injury or accident to your eye(s) in the past ?*
(type N/A if you do not have any )
Please provide any medical condition(s)*
(type N/A if you do not have any, e.g. diabetes, high blood pressure)
Please provide the list of medication(s)*
(type N/A if you do not have any )
Please provide the name of eye drop(s) you use*
(type N/A if you do not have any )
Please list any allergies you may have to any medications/eyedrops*
(type N/A if you do not have any )
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.*
YesNo
Signature
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