Location*

Date:*

Name*

Last First Middle

Date of Birth:*

Health Card #:*

Version Code:*

Expiry Date:*

Gender:*

Male
Female
Other

Address:*

Street Address Address Line 2 City Province Postal Code

Telephone #:*

Home Work Cell

Email Address:*

Occupation:

Referred By:

Family Doctor:

Last Eye Exam:

Medications

(please list ALL current medications including eye drops, injections, and health devices that you are currently using.
This includes prescription and non-prescription items.)

What is your primary reason for your examination today?

Health History

(please check any conditions which apply to you)

If cancer, please specify the type:

If other, please specify:

Eye Health

(please check any conditions which apply to you)

If other, please specify:

Family Health History

(please check any conditions someone in your family has had and note the relationship below)

If other, please specify:

For all the conditions checked above (under Family Health History), please specify the condition and relationship to you:

Condition	Relationship

What are your hobbies?

Do you work on a computer?*

Yes
No

Do you wear contact lenses?*

Yes
No

Do you drive?*

Yes
No

Do you smoke?*

Yes
No

Do you work at a job that requires safety glasses?*

Yes
No

Are you interested in refractive surgery vision correction?*

Yes
No

PATIENT PRIVACY PROTECTION FORM

NOTE TO PATIENT: We want your informed consent. This means that we want you to understand the services we will provide you, and what we do with the personal information we obtain from you. If you have a question on any of this, please ask.

CONSENT FOR PERSONAL INFORMATION

I understand that to provide me with optometric services and products, Mississauga Vision Centre Inc. and Brampton Vision Centre will collect some personal information about me (e.g. home telephone number, address, OHIP number, medications used).

I know that at any time, I can request to review Mississauga Vision Centre Inc.’s and Brampton Vision Centre Inc.’s Privacy Policy with respect to the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information. I have been given a chance to ask any questions I have about the Privacy Policy and how it applies to me.

I understand that I may receive without request, some of the following notices and information. If I do not want to receive some of this information, I agree to advise Mississauga Vision Centre Inc. and Brampton Vision Centre Inc.’s of my refusal in writing:
• Notice when it is time to review my eye and vision care needs, including reminder notices for another eye examination
• Newsletters and other informational mailings from Mississauga Vision Centre Inc. and Brampton Vision Centre Inc.
• Notice of promotions and special offers from Mississauga Vision Centre Inc. and Brampton Vision Centre Inc.

I understand that, as explained in the Privacy Policy, there are some rare exceptions to these commitments.

I agree to Mississauga Vision Centre Inc. and Brampton Vision Centre Inc. collecting, using and disclosing personal information about me as set out above and in Mississauga Vision Centre Inc.’s and Brampton Vision Centre Inc.’s Privacy Policy.

Signature:*

Name:*

First Last

Date:*

Patient Registration Form

PATIENT PRIVACY PROTECTION FORM

CONSENT FOR PERSONAL INFORMATION

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