• 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.
  • 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.

  •  -  -
    Pick a Date
  •  -  -
    Pick a 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)

  •  -  -
    Pick a Date


  •  -  -
    Pick a Date
  • 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.

  •  
  • Clear
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm