New Patient Registration Form | Dr. Jeff Sciberras

* Denotes Mandatory Field
Name*

FirstLast
Date of Birth*

MonthDayYear
MaleFemaleNon-BinaryOther
OHIP Number*
Required for all OHIP eligible exams.
OHIP Number
Input if patient is under age of 20 or over age of 65
Home Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Email*
Phone Number*
Format: (000) 000-0000.
PhoneEmail
Family Doctor
GlassesContact LensesNone
Dry EyesNeed Contact LensesNeed GlassesFlashing Lights / FloatersSudden Vision LossMyopia ManagementHeadachesRed EyesRoutine CheckupOther
Provide details:*
What year was your last eye exam?*

Are you being treated or monitored for any of the following health conditions?*

YesNo
Please list the health conditions that you are being treated or monitored for.
Please list all medications you are currently taking:
YesNo
Please provide details about the eye surgery or surgeries you have had in the past.
YesNo
Please list the prescription or over the counter eye drops that you use, and please bring them to your visit.

Have you been diagnosed with:*