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180 Bloor Street West, Unit 603, Toronto, ON M5S 2V8

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COVID-19 Updates
Hours & Location
Our Eye Doctors
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

COVID-19 Updates
Hours & Location
Our Eye Doctors
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

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Home » Contact Us » Patient Registration Form

Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
Prefix First Last
Address*
Street Address Address Line 2 City Province Postal Code
Phone Number*
Cell phone preferred as we will text you reminders/confirmations.
Is the above number a cell phone?*
- Yes
- No
Email Address*
Please provide us your email address.
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Employer
Occupation
How were you referred to our office?
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
Eye History
Please check off any current conditions you suffer from
- I stopped wearing glasses
- I stopped wearing contact lenses
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:
Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- Considering laser surgery
- Considering contact lenses
- Poor vision with glasses
- Want to purchase new frames
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
- Acuvue
- Alcon
- Coopervision
- Bausch and Lomb
- Unknown
What kind of contacts do you wear?
- For nearsightedness
- For farsightedness
- For astigmatism
- Bifocal / Multifocals
- Hard lenses/ Rigid Gas Permeables
- OrthoKertology
- I don't know
How often do you throw out your contacts
- Daily
- Every 2 weeks
- Every month
- Every 3 months
- Every 6 months
- Every year
- More than 1 yr
How old are your current lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- Poor vision with contacts
- Dry Eyes
- Problems reading up close
- I am happy with my contacts
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
Who is your primary care physician?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
We are able to directly bill SOME, not all insurance. Please check with your provider to find out your coverage before you arrive. Waiting time will be minimized if insurance info is provided here.
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
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
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Untitled
Phone
This field is for validation purposes and should be left unchanged.

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Annex Eyecare

180 Bloor Street West, Unit 603
Toronto, ON M5S 2V8

Phone: 416-925-6103
Email: info@annexeyecare.ca
(Do not send personal health information by email.)

Monday: 10:00 AM - 6:00 PM
Tuesday: 10:00 AM - 6:00 PM
Wednesday: 10:00 AM - 6:00 PM
Thursday: 10:00 AM - 6:00 PM
Friday: 10:00 AM - 6:00 PM
Saturday: 10:00 AM - 4:00 PM
Sunday: Closed

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Eyeglasses
Contact Lenses
Insurance

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Annex Eyecare - Located at 180 Bloor Street West, Unit 603, Toronto, ON M5S 2V8 Phone: 416-925-6103

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