New Patient Form New Patient Registration Form Patient InformationName* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone NumberCell PhoneEmail AddressPersonal InformationGender*FemaleMaleDate of Birth* Date Format: MM slash DD slash YYYY MSP number*OccupationDo you have coverage through the following? Indian Status Human Resources Healthy Kids Eye HistoryMain reason for examinationRoutine, blurred vision, double vision, new floaters etc.Date of last eye exam?Eye conditionsDo you have any eye conditions - glaucoma, macular degeneration, retinal detachments, lazy eye/strabismus?Ophthalmologist (if applicable)Previous eye surgeriesCataract extraction, corneal transplant, LASIK/PRK etc.Family history of eye conditionsPlease list any eye conditions that run in your family - glaucoma, macular degeneration.Glasses HistoryDo you wear glasses?*YesNoWhat glasses do you own? Single Vision Bifocals Progressive Office Progressives Trifocals Other Do you want to schedule an appointment to purchase glasses after your appointment? Yes No We are booking separate optical appointments during the COVID-19 pandemic to control the number of people in the optical.Contact Lens HistoryDo you wear contact lenses?*YesNoType of Contact Lenses Spherical Toric Multifocal Monovision Daily Monthly Biweekly Other BrandRight powerLeft powerContact Lens SolutionMedical HistoryFamily DoctorCurrent medical conditionsDiabetes, hypertension, auto-immune conditions etc.Current prescription medicationsDrug allergiesPrimary InsuranceInsured's Name First Last Please bring all insurance cards with you to your appointment.Insurance Company NameIdentification NumberGroup NumberInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to InsuredSecondary InsuranceDo you have secondary insurance?YesNoInsurance Company NameInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to InsuredCommentsAny additional comments?CommentsThis field is for validation purposes and should be left unchanged.