New Patient Registration Form "*" indicates required fields Date of Your Appointment MM slash DD slash YYYY Gender* Male Female Name* First Last Date of Birth* MM slash DD slash YYYY PhoneHealth card numberEmail* Address* Street Address Address Line 2 City Region/State/Province Postal Code What is the reason for your visit? Blurred far vision Blurred near vision Headaches Eye redness Eye pain Others Explain otherMedical Conditions: Diabetes High Blood Pressure Cholesterol Thyroid Other Explain Other Condition(s):Please List all the Medications you are takingWe do direct billing to insurance companiesPolicy Number;Member ID:Name of the Primary Policyholder:Date of birth: MM slash DD slash YYYY How did you find us:* Website Google Ad Social Media (Facebook, Instagram) Family Doctor Friend By supplying my home/cell phone number, email address and any other personal information, I authorize Dr. Deol & Associates Family Eye Care to use my personal information to contact me with respect to appointment times, referral notices, results information, appointment reminders, and other limited information. I also consent to the sharing of this information with other physicians within my circle of care including my family physician or specialist.SignatureCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
