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Home » Contact Us » Patient Registration Form

Patient Registration Form

Brampton Family Eye Care - Dr. Arinder Basra & Associates, OD

Name
First Middle Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Occupation
Email
How long since your last eye exam
Health Card (OHIP) Number
Name of Insurance
Policy #
Member ID
How did you hear about us
Main Reason(s) for today’s visit (please check)
- Routine Eye Exam
- Damaged Glasses
- Eye Strain
- Blurry Distance Vision
- Irritated/Painful Eye(s)
- Contact Lens Check
- Blurry Near Vision
- Dry/Watery Eye(s)
Other
Have you ever had an eye injury or infection?
- Yes
- No
Have you ever had eye surgery?
- Yes
- No
Do you wear glasses/reading glasses?
- Yes
- No
Do you wear contact lenses?
- Yes
- No
Are you interested in trying contact lenses?
- Yes
- No
Are you pregnant? (if applicable)
- Yes
- No
Please list any health conditions you have
Please list medications you take
Please list any known allergies
Please indicate if you have a family history of
- Glaucoma
- Crossed/Lazy Eye
- Diabetes
- Macular Degeneration
- Retinal Detachment
- Thyroid Conditions
- Cataracts
Other
Do you consent to the use of diagnostic eye drops (dilation drops)?
- Yes
- No
Do you consent to our office emailing you to confirm your future eye exam appointments and send promotional offers/sales on glasses and contact lenses?
- Yes
- No
Signature
Date
MM slash DD slash YYYY

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Brampton Family Eye Care

65 Montpelier Street, Unit #E-103
Brampton, ON L6Y 6H4

Phone: 905-497-1422
Fax: 905-497-1522
Email: bramptonfamilyeyecare@gmail.com
(Do not send personal health information by email.)

Monday: 10:00 AM - 5:00 PM
Tuesday: 10:00 AM - 6:00 PM
Wednesday: 10:00 AM - 7:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 10:00 AM - 5:00 PM
Saturday: 10:00 AM - 3:00 PM
Sunday: 10:00 AM - 3:00 PM

Brampton Family Eye Care in Brampton, ON

Our office is located at 65 Montpelier Street, Unit #E-103 Brampton Ontario L6Y 6H4.

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905-497-1522

Brampton Family Eye Care
65 Montpelier Street, Unit #E-103
Brampton, ON L6Y 6H4
Phone: 905-497-1422
https://www.bramptonfamilyeyecare.com

Email:
bramptonfamilyeyecare@gmail.com
(Do not send personal health information by email.)

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