Eye Clinic Patient Registration Form

Register your ophthalmology patients online: personal and contact details, symptom screening, reason for the visit, medical history, and communication consent. Less paperwork at the front desk and complete records from day one.

Use this template

Patient Name

Nombre

Apellido

Sex

Female Male Prefer not to say

Date of Birth

Home Address

Dirección

Ciudad

Estado / Provincia

Código postal

Did you provide care or have close contact with a person with COVID-19 without wearing the appropriate PPE?

Yes No Not sure

Do you have any of the following new or worsening symptoms or signs?

Do you need new eyeglasses?

Yes No Not sure

Are you a contact lens wearer?

Yes No Occasionally

Are you a new or existing patient?

New Existing Returning after several years

Current Date

Health insurance information

OHIP Number

Version Code

Date

Primary Phone Number

Is this a mobile (cell) phone?

Yes No It is a landline

Alternative Phone Number

Is this a mobile (cell) phone?

Yes No It is a landline

Name of Parent (or Guardian)

Occupation

How did you hear about us?

Name of your Family Doctor

Name of previous Optometrist

Last Eye Exam

Vision health history

Tell us about your visit and your medical background.

What is the main reason for this appointment?

If you have any symptoms related to your eye condition, please provide details.

Do you have any headaches? If so, what type, when, and how often do you get them?

Have you had any injuries or accidents in the past?

Have you had any injury or accident to your eye(s) in the past?

Please provide any medical condition(s)

Please provide the list of medication(s)

Please provide the name of the eye drop(s) you use

Please list any allergies you may have to medications or eye drops

I consent to the eye clinic contacting me regarding my medical reports and education about my vision and ocular health using the contact information I have provided.

I consent I do not consent Only appointment reminders

Signature

Sign here

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