Routine Patient Registration Form

1 Step 1
Dr. J. Deol & Associates Family Eye Care
Date Of Your Appointment
Last Name
First Name
Date of Birth:of appointment
City:your full name
Postal code:your full name
Cell Ph:your full name
Version Code
What is the reason for your visit?
Other reason for your visit?your full name
Medical Conditions:
Other Medical Conditions:your full name
Please List All The Medications You Are Taking
0 /
We do direct billing to insurance companies
*Only Fill In If Has Changed In The Last Year
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
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)?
2. Do you have any of the following symptoms:
Dry cough?
Shortness of breath?
Difficulty breathing?
Sore throat?
Runny nose?
Diarrhea ?
3. Does anyone in your household have any of the above symptoms ?
4. Have you experienced a recent loss of smell or taste?
5. Have you been in contact with any covid 19 +ve patients, or persons self isolating because of a risk for COVID-19?
6. Have you returned from travel outside of Canada in the last 14 days?
7. Have you returned from travel within Canada from a location known affected with COVID-19?
I am verifying that all the above statements are true.
Please type your initials:
FormCraft - WordPress form builder