Patient Registration Form Patient 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.Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Number*Please provide a telephone number, with area code, so we can contact you.Phone Type* Home Cell Work Additional Contact NumberPhone Type Home Cell Work Email Address*Please provide us your email address.Personal InformationGender*FemaleMaleDate of Birth* Date Format: DD slash MM slash YYYY OccupationHow were you referred to our office?*Select Referral Type >Friend or FamilyFamily DoctorOphthalmologistLive in the areaInsurance CompanyAdvertisingReceived MailingInternetOther OptometristOtherCommunication Preference*EmailTextPlease indicate how you would prefer to receive Appointment Reminders and RecallsFamily Physician*Please provide first and last name. Additional Family MembersPlease complete if multiple members from your family have an appointment. Add Additional Family Members*yesno1) Name First Last Date of Birth Date Format: DD slash MM slash YYYY Family Physician2) Name First Last Date of Birth Date Format: DD slash MM slash YYYY Family Physician3) Name First Last Date of Birth Date Format: DD slash MM slash YYYY Family Physician4) Name First Last Date of Birth Date Format: DD slash MM slash YYYY Family Physician5) Name First Last Date of Birth Date Format: DD slash MM slash YYYY Family PhysicianManitoba Health Card Please upload a picture of your MB Health Card. You may choose to bring card to appointment if you do not have details on hand.Upload a picture of your MB Health Card Drop files here or **Please provide a copy of the front and back of your MB Health CardPrimary Insurance (Optional)Please bring all insurance cards with you to your appointment.Insurance Company NameInsurance Company Phone NumberInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to InsuredSecondary InsuranceDo you have secondary insurance?YesNoIf you have coverage through another plan/organization, please fill in the details below.Insurance Company NameInsurance Company Phone NumberInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to InsuredCommentsIf you have any comments you would like to add, please enter them here.Enhanced Eye ExamA 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?*yesnounsureUnsure? 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 PolicyHealth Information Protection* I have read and agree to the Privacy Policy Do you wish to receive emails containing information regarding new products and promotions from Sage Creek Eye Centre? yes no SignaturePost Title Untitled First Choice Second Choice Third Choice PhoneThis field is for validation purposes and should be left unchanged.
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