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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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* Female Male Pronouns* she/her he/him they/them Date of Birth* DD slash MM slash YYYY Occupation How 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* yes no 1) Name First Last Date of Birth DD slash MM slash YYYY Family Physician 2) Name First Last Date of Birth DD slash MM slash YYYY Family Physician 3) Name First Last Date of Birth DD slash MM slash YYYY Family Physician 4) Name First Last Date of Birth DD slash MM slash YYYY Family Physician 5) Name First Last Date of Birth DD slash MM slash YYYY Family Physician Manitoba Health Card Please Bring your Manitoba Health card to Appointment.Primary Insurance (Optional)Please bring all insurance cards with you to your appointment.Insurance Company Name Insurance Company Phone NumberInsured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Secondary InsuranceDo you have secondary insurance? Yes No If you have coverage through another plan/organization, please fill in the details below.Insurance Company Name Insurance Company Phone NumberInsured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured CommentsIf 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?* yes no unsure 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 PolicyI have read and understand below* Yes 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. SignatureCommentsThis field is for validation purposes and should be left unchanged.
Insurance Plans We Accept