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

Name*

Prefix First Last Suffix

Date of Birth*

Gender*

Female
Male
Other

Health Card Number*

10 digit number on your health card. If not applicable, please put N/A

Version Code*

The two characters following 10 digit health card number. If not applicable, please put N/A

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone Number

Cell Phone*

Work Phone

Email Address*

Please provide your email, in order for us to provide access to complete forms online, email receipts, and receive appointment reminders.

Communication Preference*

Consent to Electronic Communications*

I, the patient, or as the Guardian/Representative of above named patient,agree to communicate with Markham Eye and Vision Care electronically

With your consent, the Optometrist may communicate with you via text message, email or other forms of electronic communication (“Electronic Communications”) for administrative purposes such as appointment scheduling, confirmation and cancellation, and to provide information and consent forms, as well as information about services, programs and other offerings. Clinic service email including the following addresses: info@eyecaremarkham.com, eyedr.wang@gmail.com, markhameyeandvisioncare@gmail.com

Personal information Protection and Electronic Documents Act (PIPEDA)*

I, the patient, or as the Guardian/Representative of above named patient, agree

All information contained herein is protected by the Personal information Protection and Electronic Documents Act (PIPEDA) and the Canadian Anti-Spam Legislation ( CASL). I also authorize MEVC to release copies of my medical documents to regulatory and other health care practitioners for further diagnosis, treatment and referrals when required and/or necessary.

You can withdraw your consent to receive Electronic Communications at any time by contacting Markham Eye and Vision Care, Dr. Yilei Wang, Optometrist.

Personal Information

Employer / School

Occupation / Grade

Employment Status

Please provide your employment status.

Marital Status

Spouse Name

If patient is a child, please enter Parent's name

Spouse Occupation

If patient is a child, please enter Parent's occupation

Please list names of other household members that are patients of our practice

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Eye History

What is the main reason for you to make this appointment*

I am due for annual eye exam
I experience problem(s) with my eyes' comfort
I experience problem(s) with my vision
I experience some problem(s) with my glasses
It's related with my contact lens
Other

Other reason for this appointment

Do you experience any problems with your current glasses?

Do you experience any problems with current contact lens

When, approximately, was your last eye exam?

Where did you get your last eye exam?

Please check off any current conditions you suffer from

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you wear?

When do you use your Single Vision Glasses

Generally
Mainly at Driving
Only at reading fine print
When use a computer

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Other glasses:

Please tell us what other kinds of glasses you own.

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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

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.

Contact Lens History

Do 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 History

When, approximately, was your last physical exam?

Who is your primary care physician?*

Primary care physician's phone number*

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please check off any current conditions you suffer from

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 hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

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Primary Insurance

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Insurance Company Name

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Insurance Company Phone Number

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Address

Street Address Address Line 2 City Province Postal Code

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Insured's Name

First Last

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Identification Number

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Group Number

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Insured's Date of Birth

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Patient's Relation to Insured

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Secondary Insurance

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Do you have secondary insurance?

Yes
No

If you have coverage through another plan/organization, please fill in the details below.

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Insurance Company Name

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Insurance Company Phone Number

Address

Street Address Address Line 2 City Province Postal Code

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

If you have any comments you would like to add, please enter them here.

Comments

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

Online Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

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Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

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