Existing Patient Registration Form

This Form Is For Existing Patients Only

If you are a new patient to our practice, please complete our New Patient Registration Form

In addition to the Patient Registration Form below, please sign and submit our Covid-19 Declaration

Each form must be submitted individually, by hitting the submit form on the bottom of this page, as well as on the bottom of the Covid-19 Declaration page

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 Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*

Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address*

Please provide us your email address.
Personal Information
Gender*
- Female
- Male
- Non-Binary
Date of Birth*
MM slash DD slash YYYY
Occupation
How were you referred to our office?
Referral Status - Other

Please let us know how you were referred to our office.
Communication Preference
Have you had any medical or eye - related changes in the past 12 months, or since your last visit with our optometrists?
- I give Milton Eyecare consent to communicate with me via email and text messaging
- I acknowledge that I will be charged a "no show" fee if I do not give 24 hours notice if I am unable to make my scheduled appointment
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Comments
This field is for validation purposes and should be left unchanged.

Please make sure to click on the submit button of this form prior to clicking on the Covid-19 Declaration page

This Form Is For Existing Patients Only

Patient Information

Personal Information

Privacy Policy

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