Registration Form for New Patients
Welcome to BCC Optometry! Please complete this registration form before your appointment.
Email address *
Select title:
First Name: *
Your answer
Last Name: *
Your answer
Guardian Name:
Your answer
Date of Birth: *
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Home Address: *
Your answer
City: *
Your answer
Postal Code: *
Your answer
Health Card Number: (Required if 19 years or younger and 65 years or older)
Your answer
Health Card Version Code (2 Letters):
Your answer
Please select ONLY if this applies to you.
Primary Phone Number: *
Your answer
Alternate Phone Number:
Your answer
Occupation:
Your answer
Family Doctor:
Your answer
Ocular History
Self
Family
Cataracts
Glaucoma
Retinal Disease
Lazy Eye
Eye Injury
Eye Surgery
Other Ocular History (Please Specify):
Your answer
Date of Last Eye Exam:
MM
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DD
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YYYY
Medical History
Self
Family
High Blood Pressure
Diabetes
Heart Disease
Cholesterol
Thyroid
Respiratory
Do you have any allergies?
Please list:
Your answer
Please list any medications (including eye drops) you are currently using:
Your answer
Communication Preferences: *
Our clinic offers the opportunity to receive next appointment reminders by email, telephone, or postcard. By selecting your preference(s) below, you are consenting to receive appointment reminders, or occasional office information using the method specified below. Your consent may be withdrawn at any time by contacting our office directly. (Please select all that apply)
Required
Date of your appointment:
If you have booked an appointment, please indicate the date below or call our office to schedule an appointment.
MM
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DD
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A copy of your responses will be emailed to the address you provided.
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