Online Patient Registration Form Name* First Last Nickname Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneDate of Birth MM slash DD slash YYYY Occupation Health Number (10 digits)Version Code (1 or 2 letters) EXP date MM slash DD slash YYYY Vision Claim Insurance Information Carrier Policy # Group# Referred by or Patient Since: Confirm email address: Reason for Visit: I have symptoms I have concerns It’s time for my regular eye health and vision exam Please check the following as they apply:I wear the following Prescription glasses for distance Prescription glasses for near Prescription glasses for computer Prescription sunglasses Contact lenses Non-prescription sunglasses I don’t wear any of these I think I need a change in the following Prescription glasses for distance Prescription glasses for near Prescription glasses for computer Prescription sunglasses Contact lenses Non-prescription sunglasses I don’t wear any of these I have the following symptoms Blurred vision at distance Blurred vision at near Blurred vision when using my computer or cell phone Headaches Double vision Burning Tearing Itching Redness Discharge Dryness Scratchy or gritty sensation Sudden onset of spots or floaters Seeing light flashes Do you have a driver’s license? Yes No Does it require you to wear glasses? Are you bothered by glare? Yes No Are you bothered by halos around lights at night? Yes No What hobbies do you have? How much time do you spend on the computer per day? How much time do you spend reading printed text? Do you spend your recreational time outdoors? Yes No Have you had any operations or injuries to your eyes? Yes No explain Have you a history of eye disease? Yes No explain Is there a history of eye disease in your family? Yes No explain Do you have or are you being treated for any health problems? Yes No (high blood pressure/diabetes/heart disease/breathing problems/autoimmune disorders) explain List the medications that you are taking and the reasons for eachDo you have environmental allergies? Yes No explain Are you allergic to any medications? Yes No explain When was your last check-up with your family doctor? Family Doctor’s name 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.
