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 Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Number*

Please provide a telephone number, with area code, so we can contact you.

Phone Type*

Home
Cell
Work

Additional Contact Number

Phone Type

Home
Cell
Work

Email Address*

Please provide us your email address.

Personal Information

Gender*

Female
Male

Pronouns*

she/her
he/him
they/them

Date of Birth*

Occupation

How were you referred to our office?*

Communication Preference*

Please indicate how you would prefer to receive Appointment Reminders and Recalls

Family Physician*

Please provide first and last name.

Additional Family Members

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

Add Additional Family Members*

yes
no

1) Name

First Last

Date of Birth

Family Physician

2) Name

First Last

Date of Birth

Family Physician

3) Name

First Last

Date of Birth

Family Physician

4) Name

First Last

Date of Birth

Family Physician

5) Name

First Last

Date of Birth

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 Number

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do 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 Number

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

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?*

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 Policy

I 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.

Signature

Comments

This field is for validation purposes and should be left unchanged.