Routine 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 Address Street Address Address Line 2 City Region/State/Province Postal Code Cell PhoneEmail* What is the reason for your visit? Blurred far vision Blurred near vision Headaches Eye redness Eye pain Others Medical Conditions: Diabetes High Blood Pressure Cholesterol Thyroid Other Explain Other Condition(s):Please List all the Medications you are takingBy 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.SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
