New Patient Form First Name Last Name Gender Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Manitoba Health Number (9 Digit) Manitoba Health Number (6 Digit) Address City Postal Code Home Phone # Business Phone # Cell Phone # Email Address Occupation Date of Last Eye Exam Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Name of Last Optometrist Family Physician's Name & Clinic How Did You Hear About Us? Please list all medications and/or eye drops you are currently using Do you wear glasses? - None -YesNo Do you wear contact lenses? - None -YesNo Our clinic is pleased to announce that we will be offering a new way to contact you in the near future. Please take a moment to fill out the section below: For appointment reminders, please select any and all methods we may use to contact you Text Message Email Phone For Order Updates (For glasses and contact lens orders), please select any and all methods we may use to contact you Text Message Email Phone For Patient Recalls (Reminders to see your optometrist), please select any and all methods we may use to contact you Text Message Email Phone May we contact you with the following information Eye Health Education Information about upcoming sales and promotions Newsletters *Please note that missed or cancelled appointments with less than 24 hours notice will incur a $50 fee Patient Consent Requirement: By entering my name below I understand that the personal information collected about me (and/or my family) and held by 20/20 Eye Care shall be limited to that which is necessary for the provision and billing for optometric services and communication with me, authorized health care providers or insurers relating to that care. I understand this information may also be disclosed to the practice’s consultants or other persons contracted to maintain the practice’s business, to a succeeding or purchasing optometric or medical practice, or to regulatory authorities for the purpose of complaints, investigations, or stand reviews. I understand that the practice will keep my personal information confidential and secure. I hereby authorize 20/20 Eye Care to collect, use, and disclose my personal information as described above. Full Name Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202520262027 Leave this field blank
