Patient Registration Form Today’s date:* MM slash DD slash YYYY Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Marital status Single Mar Div Sep Wid If under 18 Parent/Guardian Name D.O.B MM slash DD slash YYYY Language Pref AgeGender Male Female Home phone noCell phone no*Work noAddress 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 Occupation Contact Email Communication Preference General Practitioner (GP) Chose clinic because/Referred to clinic by Dr Google Ad Family Close to home/work Friend Other family members seen here Please indicate your health coverage (if applicable) NHIB OW/ODSP OHIP Please indicate your insurance company (if applicable) Manulife Great West Life GreenShield Blue Cross Sunlife *Please read the following and check the boxes below ** The above information is true to the best of my knowledge. I, authorize my insurance benefits be paid directly to Ancaster Family Eyecare. I understand that I am financially responsible for any balance. I also authorize Ancaster Family Eyecare or insurance company to release any information required to process my claims. I, consent to Ancaster Family Eyecare to sending me appointment reminders, by email, SMS or Text Message. I understand I can withdraw my consent at any time by contacting Ancaster Family Eyecare. Signature*Date MM slash DD slash YYYY Reason for Appointment Routine Exam Emergency Blurry Vision Headaches Diabetic Check Lasik Poor Night Vision Itchy Eyes Contacts Red Eyes Glasses Sports Googles/ Safety Sunglasses Eye HistoryDo you wear glasses? Yes No How old are your current glasses What do you primarily use your glasses for When, approximately, was your last eye exam? Where Do you wear contact lenses? Brand Please list any eye conditions you have been diagnosed with (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)Medical HistoryWhen, approximately, was your last medical physical exam? Do you smoke? Yes No Are you Pregnant or nursing? Yes No (If applicable) Please List any current medical conditions you have: (Diabetes, High blood pressure, Arthritis, etc.)Please list any prescription and over-the-counter medications you take: (or provide a list to receptionist)Please indicate if there is a history of surgery or major eye injuriesPlease indicate if there is a history of surgery or major eye injuriesPlease list any drug or environmental allergies
