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Clinic Hours
Mon - Wed : 11am - 7pm
Thu - Sat : 10am - 7pm
Sun : 11am - 7pm
Our Office
4520 Ebenezer Road, Unit 1 Brampton, ON - L6P 2R2
Call Us
905-913-1109
Book Eye Exam
Menu
Home
Services
Dry Eye Treatment
Blepharitis
Astigmatism
Far sighted & Near sighted
Cataracts
Red Eye or Conjunctivitis
Hordeolum
Uveitis or Eye Inflammation
Contact Lenses
Diabetes
Glaucoma
Eye Injury
Laser Surgery
Ophthalmologist Consult Referral
Myopia Management
OCT Scan
+
About Us
Brands
Directions
New Patient Registration Form
Routine Patient Registration Form
Eye Exam Referral Form
New Patient Registration Form
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New Patient Registration Form
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1
Step 1
Dr. J. Deol & Associates Family Eye Care
Date Of Your Appointment
date_range
Gender:
Male
Female
Last Name
First Name
Date of Birth:
of appointment
date_range
Address:
your full name
City:
your full name
Postal code:
your full name
Email
a valid email
email
Health Card No (Version Card)
Phone Number
Health Card Expiry:
date_range
Version Code
What is the reason for your visit?
Blurred far vision
Blurred near vision
Headaches
Eye redness
Eye pain
Other
Other reason for your visit?
your full name
Medical Conditions:
Diabetes
High Blood Pressure
Cholesterol
Thyroid
Other Medical Conditions:
your full name
Please List All The Medications You Are Taking
0
/
We do direct billing to insurance companies
Name of Insurance company:
your full name
Policy Number:
your full name
Member Id:
your full name
Name of the Primary policyholder:
your full name
Date of Birth:
of appointment
date_range
Pre-appointment screening for COVID-19:
1. Do you have a fever or have felt hot or feverish anytime in the last two weeks (14 days)?
Y
N
2. Do you have any of the following symptoms:
Dry cough?
Y
N
Shortness of breath?
Y
N
Difficulty breathing?
Y
N
Sore throat?
Y
N
Runny nose?
Y
N
Diarrhea ?
Y
N
3. Does anyone in your household have any of the above symptoms ?
Y
N
4. Have you experienced a recent loss of smell or taste?
Y
N
5. Have you been in contact with any covid 19 +ve patients, or persons self isolating because of a risk for COVID-19?
Y
N
6. Have you returned from travel outside of Canada in the last 14 days?
Y
N
7. Have you returned from travel within Canada from a location known affected with COVID-19?
Y
N
How Did You Hear About Us:
Family or Friends
Website
Google Ad
Clinic Sign
Optical Sign
Family Doctor Referral
I am verifying that all the above statements are true.
Please type your initials:
Submit Form
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MENU
Home
Services
Dry Eye Treatment
Blepharitis
Astigmatism
Far sighted & Near sighted
Cataracts
Red Eye or Conjunctivitis
Hordeolum
Uveitis or Eye Inflammation
Contact Lenses
Diabetes
Glaucoma
Eye Injury
Laser Surgery
Ophthalmologist Consult Referral
Myopia Management
OCT Scan
About Us
Brands
Directions
New Patient Registration Form
Routine Patient Registration Form
Eye Exam Referral Form
Book Eye Exam
Call Us:
905-913-1109
or
Email Us:
drdeolfamilyeyecare@gmail.com
or
Fill the form below:
[]
1
Step 1
Your Phone Number
Your Name
Your Email Address
email
Date of Birth
date_range
Patient Type
Routine Patient
New Patient
Preferred Day of Week
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Best Time for Appointment
Morning
Afternoon
1st preffered Date
date_range
Am
Pm
Anytime
2nd preffered Date
of appointment
date_range
Am
Pm
Anytime
Reason For Appointment
Comprehensive Adult Eye Exam
Comprehensive Child Eye Exam
Eye Redness
Diabetic Eye Exam
Glaucoma Testing & Visual Field Screening
Cataracts Diagnosis & Surgery Co-Management
Laser Vision Consult & Co-Management
Contact Lens Fitting
Ministry of Transportation Driving Vision Testing
Police Vision Testing
Eye Injuries
Dry Eye Syndrome
Comments/Questions
0
/
Privacy Policy
How Would You like to reach you back
By Email
By Phone
By Text
Submit
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