*Final*Eastgate Eye Clinic Patient Registration Form

Eastgate Eye Clinic Patient Registration Form

Please fill in the form below. This form must be submitted to the clinic prior to booking an appointment. To ensure the safety of our patients and staff, all patients MUST wear a mask before entering the office. If you do not bring your mask, we can not see you and your appointment will be rescheduled. At this time, we are NOT direct billing to insurance providers. Only patients with an appointment are permitted in the office, with the exception of a personal caregiver or a parent/guardian accompanying a minor.
In the past 14 days, did you travel outside of Canada or had close contact with anyone that has traveled outside of Canada? *

Yes No
Did you provide care or have close contact with a person with COVID-19 without wearing the appropriate PPE? *

Yes No
Do you have any of the following new or worsening symptoms or signs? *

Yes No

Fever	Headache	Chills
New or worsening cough	Shortness of breath	Sore throat
Runny nose, sneezing, nasal congestion	Hoarse voice	Difficulty swallowing
New smell or taste disorder(s)	Nausea/vomitting, diarrhea, abdominal pain	Unexplained fatigue/malaise

Unfortunately, we can not accommodate you at this time.

Seek immediate medical attention if you have serious symptoms. Always call before visiting your doctor or health facility.

Do you need new eye glasses? *

Yes No
Are you are a contact lens wearer? *

Yes No
Are you a "New" or "existing" patient? *

New Existing
Patient Name *

First Name Middle Name Last Name
Sex *

Male Female
Date of Birth *

Month Day Year
Date
Home Address *

Street Address

Street Address Line 2

City Province

Postal Code Country
(HIDE)Calculation
(HIDE)Current Date

Month Day Year
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 *
Expiry Date

Month Day Year
Date
Primary Phone Number *
Mobile (cell phone)? *

Yes No
Alternative Phone Number
Mobile (cell phone)?

Yes No
Email *
example@example.com
Name of Parent (or Guardian)
Occupation
How did you hear about us?
Name of your Family Doctor

I don't know I don't have one
Name of previous Optometrist

I don't know I don't have one
Last Eye Exam

Month Day Year
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"

Blurry Vision "when I need to see Far"

Blurry Vision "when I wear glasses"

Blurry Vision "when I DO NOT wear glasses"

Diplopia(Double Visions)

Flashes

Floaters

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/eye drops *
(type N/A if you do not have any )

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

Yes No
Signature

Clear
Should be Empty:

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