Online Patient Registration Form

lock icon

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
Prefix First Last Suffix
Date of Birth*
MM slash DD slash YYYY
Gender*
- Female
- Male
- Other
Health Card Number*

10 digit number on your health card. If not applicable, please put N/A
Version Code*

The two characters following 10 digit health card number. If not applicable, please put N/A
Address*
Street Address Address Line 2 City Province Postal Code
Home Phone Number
Cell Phone*
Work Phone
Email Address*

Please provide your email, in order for us to provide access to complete forms online, email receipts, and receive appointment reminders.
Communication Preference*
Consent to Electronic Communications*
I, the patient, or as the Guardian/Representative of above named patient,agree to communicate with Markham Eye and Vision Care electronically
With your consent, the Optometrist may communicate with you via text message, email or other forms of electronic communication (“Electronic Communications”) for administrative purposes such as appointment scheduling, confirmation and cancellation, and to provide information and consent forms, as well as information about services, programs and other offerings. Clinic service email including the following addresses: info@eyecaremarkham.com, eyedr.wang@gmail.com, markhameyeandvisioncare@gmail.com
Personal information Protection and Electronic Documents Act (PIPEDA)*
I, the patient, or as the Guardian/Representative of above named patient, agree
All information contained herein is protected by the Personal information Protection and Electronic Documents Act (PIPEDA) and the Canadian Anti-Spam Legislation ( CASL). I also authorize MEVC to release copies of my medical documents to regulatory and other health care practitioners for further diagnosis, treatment and referrals when required and/or necessary.
You can withdraw your consent to receive Electronic Communications at any time by contacting Markham Eye and Vision Care, Dr. Yilei Wang, Optometrist.
Personal Information
Employer / School
Occupation / Grade
Employment Status

Please provide your employment status.
Marital Status
Spouse Name

If patient is a child, please enter Parent's name
Spouse Occupation

If patient is a child, please enter Parent's occupation
Please list names of other household members that are patients of our practice
How were you referred to our office?
Referral Status - Other

Please let us know how you were referred to our office.
Eye History
What is the main reason for you to make this appointment*
- I am due for annual eye exam
- I experience problem(s) with my eyes' comfort
- I experience problem(s) with my vision
- I experience some problem(s) with my glasses
- It's related with my contact lens
- Other
Other reason for this appointment
Do you experience any problems with your current glasses?
Do you experience any problems with current contact lens
When, approximately, was your last eye exam?
Where did you get your last eye exam?
Please check off any current conditions you suffer from
- I stopped wearing contact lens
- I stopped wearing glasses
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
- None of the above symptoms
I stopped wearing glasses because:
I stopped wearing contact lenses because:
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you wear?
- Single Vision
- Progressive
- Bifocals
- Trifocals
- Safety Glasses
- Sports Glasses
- Sunglasses
- Other
When do you use your Single Vision Glasses
- Generally
- Mainly at Driving
- Only at reading fine print
- When use a computer
Hidden
Other glasses:

Please tell us what other kinds of glasses you own.
Hidden
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription
Medical History
When, approximately, was your last physical exam?
Who is your primary care physician?*
Primary care physician's phone number*
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please check off any current conditions you suffer from
- Chronic fever, unexpected weight loss/gain, fatigue
- Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
- Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
- Respiratory problems (eg. Shortness of breath, wheezing, coughing)
- Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
- Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
- Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
- Skin problems (eg. Rashes, excessive dryness, growths or lumps)
- Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
- Psychiatric problems (eg. Depression, anxiety)
- Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
- Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
- Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
- Not applicable
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Hidden
Primary Insurance
Hidden
Insurance Company Name
Hidden
Insurance Company Phone Number
Hidden
Address
Street Address Address Line 2 City Province Postal Code
Hidden
Insured's Name
First Last
Hidden
Identification Number
Hidden
Group Number
Hidden
Insured's Date of Birth
MM slash DD slash YYYY
Hidden
Patient's Relation to Insured
Hidden
Secondary Insurance
Hidden
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Hidden
Insurance Company Name
Hidden
Insurance Company Phone Number
Address
Street Address Address Line 2 City Province Postal Code
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Comments
This field is for validation purposes and should be left unchanged.

Online Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Follow Us

Latest News

Our Markham Location

Hours

1-905-471-8118

Our Location

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Follow Us

Latest News

Our Markham Location