*Final*Eastgate Eye Clinic Patient Registration Form

LivingHope Vision Clinic Patient Registration Form

Thank you for visiting Livinghope Vision Clinic. Please fill in the form below. Our Staff member will schedule you to book an eye exam.
In the past 14 days, did you travel outside of Canada or had close contact with anyone that has traveled outside of Canada?*

YesNo
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?*

YesNo

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?*

YesNo
Are you are a contact lens wearer?*

YesNo
Are you a "New" or "existing" patient to Eastgate Eye Clinic?*

NewExisting
Patient Name*

First NameMiddle NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
(HIDE)Calculation
(HIDE)Current Date

MonthDayYear
Date
Health Card Information

(if you don't have OHIP card, please call our office to book an appointment )
Are you supported via social assistant by government?(e.g, ODSP, OW etc.)*

YesNo
OHIP Number*
Version Code*
Expiry Date

MonthDayYear
Date
Primary Phone Number*
Format: (000) 000-0000.
Mobile (cell phone)?*

YesNo
Alternative Phone Number
Format: (000) 000-0000.
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 oneOther
Name of previous Optometrist

I don't knowI don't have oneOther
Last Eye Exam

MonthDayYear
Date doesn't need to be accurate
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)

Rows	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. *

YesNo
Signature
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LivingHope Vision Clinic Patient Registration Form