Skip to main content
Home » Contact Us » Online Patient Registration Form

Online Patient Registration Form


  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Vision Claim Insurance Information

  • Reason for Visit:

  • Please check the following as they apply:
    (high blood pressure/diabetes/heart disease/breathing problems/autoimmune disorders)
  • The provision of your insurance coverage allows us to prepare the necessary documentation for your vision claim in advance of your visit. This minimizes the time spent in unnecessary conversation as per COVID-19 protocols. Junction Optometrists collects personal information for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibility for benefits and/or services; to arrange payment for services; and as required by law.

    The collection of this information is authorized by the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Health Protection and Promotion Act. We will take all reasonable steps to ensure that your personal information is treated confidentially and is only used for the purpose for which it was collected. We will take all reasonable steps tp prevent unauthorized access, use or disclosure of your personal information

    I acknowledge that I will be charged a fee of $95 for failing to show at the appointed time, or for cancelling my appointment within 24 hours of my scheduled appointment time.