top of page

New Patient Registration

Birthday
Month
Day
Year
1. What is the reason(s) for your visit? Please select all that apply.
3. What type(s) of eyeglasses do you own? Please select all that apply
4. Do you have any of the following medical conditions? Please select all that apply
Cancellation Policy Agreement
I agree

I understand that EyeWorld Optometry requires at least 24 hours’ notice for cancellations or changes. Failure to do so may result in a cancellation fee.

Financial Responsibility Agreement
I agree

I understand that OHIP and insurance coverage may vary and that I am responsible for any fees not covered. I agree to pay the full cost of services rendered at the time of my appointment or upon billing notification.

Privacy Policy & Consent to Communicate
I agree

I understand that EyeWorld Optometry collects and uses my personal information to provide eye care services. I consent to be contacted via email, phone, or text for appointment reminders and updates.

bottom of page