Patient Registration Form Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Please provide a telephone number, with area code, so we can contact you.Daytime PhoneCell PhoneEmail AddressPlease provide us your email address.Personal InformationDate of Birth* MM slash DD slash YYYY Social Insurance NumberOccupationHow were you referred to our office?Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherReferral Status - OtherPlease let us know how you were referred to our office.Communication PreferenceEmailPostalTelephoneEye HistoryPlease check off any current conditions you suffer from I stopped wearing glasses I stopped wearing contact lenses Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision I stopped wearing glasses because:I stopped wearing contact lenses because:Glasses HistoryDo you wear glasses?* Yes No What glasses do you own? Single Vision Bifocals Safety Glasses Backup Glasses Progressive Trifocals Sports Glasses Sunglasses Other Other glasses:Please tell us what other kinds of glasses you own.How many hours a day do you use a computer?Please enter a number from 0 to 24.How many inches away, approximately, do you sit from your computer monitor?Please enter a number from 0 to 120.Please check off any current conditions you suffer from I am having problems with my current glasses There are times when I would rather not be wearing glasses I have problems with glare I have problems with night vision I am allergic to nickel (e.g. frames of glasses) I don’t have spare set of glasses My spare glasses have an incorrect prescription My sunglasses are missing UV (ultra-violet) protection Contact Lens HistoryDo you wear contact lenses?* Yes No What brand of contact lenses do you wear?How old are your current lenses?How often do you replace or dispose your contact lenses?What brand of solution do you soak your lenses in?What is your typical wearing schedule? In hours per day:Please enter a number from 0 to 24.What is your typical wearing schedule? In days per week:Please enter a number from 0 to 7.Please check off all that apply to you I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in changing or enhancing my eye color I am interested in a non-surgical method of vision correction I am interested in refractive laser surgery I don't have a spare set of contact lenses My spare contact lenses have an incorrect prescription Medical HistoryWhen, approximately, was your last eye exam?Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)Please list all prescription and over-the-counter medications you take and for what conditionsPlease list all drug allergies you haveCommentsIf you have any comments you would like to add, please enter them here.PhoneThis field is for validation purposes and should be left unchanged. 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We have extended hours in the evening on alternating Tuesdays, please call to confirm. We are open on Saturdays for your convenience.