New Patient Form

Registration Form

Please complete the information below prior to appointment and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Name

Address

Contact Information

Personal Information

GenderFemaleMale

Pronounsshe/herhe/himthey/them

Date of Birth

Communication Preference (for appointment reminders and recalls)EmailText

Additional Family Members

Please complete if multiple members of your family have an appointment.

#1

Date of Birth

#2

Date of Birth

#3

Date of Birth

#4

Date of Birth

#5

Date of Birth

Manitoba Health Card

Please bring your Manitoba Health card to your appointment.

Primary Insurance (Optional)

Please bring all insurance cards with you to your appointment.

Insured's Date of Birth

Secondary Insurance (Optional)

If you have coverage through another plan/organization, please fill in the details below.

Insured's Date of Birth

Comments

If you have any comments you would like to add, please enter them here.

Enhanced Eye Exam

A dilated eye exam allows the doctor to get a much better, more thorough view of the back of your eyes by making the pupil (the black part of the eye) much larger. This requires the optometrist to put drops into your eyes which may cause sensitivity to light and blurry vision up close for 4-6 hours. Dilated eye exams are strongly recommended for all patients.

Are you interested in a dilated eye exam?YesNoUnsure

Unsure? Our Doctor would be happy to discuss during the exam. The fee associated with a routine dilated eye exam is an additional $40. In some cases, this service may be covered by Manitoba Health.

Privacy Policy

I authorize the release of medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payors, &/or health practitioners required to participate in my care. I authorize/ request my insurance company to make direct payment to Sage Creek eye centre . I understand that I am financially responsible for charges not covered by my insurance plan. *Accepted forms of payment: Cash, Visa, Mastercard, American Express, Interac.

I have read and understand the above Privacy Policy

Digital Signature

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Patient Registration Form

Registration Form

Name

Address

Contact Information

Personal Information

Additional Family Members

#1

#2

#3

#4

#5

Manitoba Health Card

Primary Insurance (Optional)

Secondary Insurance (Optional)

Comments

Enhanced Eye Exam

Privacy Policy

Get in touch to
book your first appointment

Patient Registration Form

Registration Form

Name

Address

Contact Information

Personal Information

Additional Family Members

#1

#2

#3

#4

#5

Manitoba Health Card

Primary Insurance (Optional)

Secondary Insurance (Optional)

Comments

Enhanced Eye Exam

Privacy Policy

Get in touch tobook your first appointment

Get in touch to
book your first appointment