Online 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 Information

Today's Date*

Name*

First Middle Last

Preferred Name

Date of Birth*

Personal Pronouns

Address*

Street Address Address Line 2 City Province Postal Code

Home Number*

Please provide a telephone number, with area code, so we can contact you.

Cell Phone

Email Address*

Please provide your email address.

Name of Guardian (if under 18)

Alberta Health Care Number*

Please enter a number less than or equal to 999999999.

Who may we thank for referring you to our office?

Name of Medical Doctor

Doctor's Phone Number

Date of Last Eye Exam

Medical History

Main reason for your visit today (please check boxes that apply)

If other, please describe

Check the box if any of the following apply to you:

Other concerns

Do you wear prescription glasses?*

Yes
No

Do you wear contact lenses?*

Yes
No

Do you take any medications?*

Yes
No

If yes, please list the medications you are currently taking:

Do you have any allergies to medications?*

Yes
No

If Yes, list medication(s):

Personal Medical History

Check the box if you or your immediate blood relatives have or have had the following conditions:

Do you have any other medical or eye conditions? Please list them here:

Are you currently pregnant or nursing?

Yes
No

Family History

Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.

Check the box if you or your immediate blood relatives have or have had the following conditions:

Do you use tobacco products?*

Yes
No

Do you have a history of smoking?*

Yes
No

Have you had eye surgery?

Yes
No

If yes, what type of surgery?

Please list the type(s) of survey and when performed.

For patients age 19 and over: Will you permit the doctor to dilate your pupils?

Yes
No

Dilation of pupils allows for more comprehensive examination of ocular health, and helps detect diseases like cataracts, glaucoma, macular degeneration, retinal tears or detachments and diabetic retinopathy. It can cause blurred vision and light sensitivity that gradually wears off over 3 to 4 hours.

Comments

This field is for validation purposes and should be left unchanged.