Patient History Form Welcome to Petrolia Optometry! Please take a moment to verify and / or update the information below. For privacy reasons, we prefer to not confirm this information out loud in front of others in the waiting area. Thank you!Patient Name: OHIP Number: D.O.B MM slash DD slash YYYY Family Physician: Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone Number:Alternate Phone Number 1: Phone number Please specify phone type (work, cell, etc) Alternate Phone Number 2: Phone number Please specify phone type (work, cell, etc) Please specify which of the above is your preferred contact number. Email Address: Alternate Contact:(reachable at a different number than the ones listed above) Contact Name: Relationship: Contact Phone Number: Guardian Information for Child PatientsGuardian 1 First Name Last Name Relationship Guardian 2 First Name Last Name Relationship PLEASE PRESENT A LIST OF MEDICATIONS TO RECEPTIONIST OR LIST BELOW: Allergies: For NEW Patients: How did you hear about Petrolia Optometry? Another Patient Internet Search Family Doctor Newspaper If you were referred to us by another patient, please specify his/her name: Petrolia Optometry 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 We need your consent IN WRITING to send ANY of your personal health information to ANYONE. Please check off all providers that you give us permission to send information/reports to WHEN REQUIRED. Family Physician Another Eye Care Professional (ie. ophthalmologist or optician) Medical Specialist (ie. a rheumatologist or internist) Nursing Home or Hospital Family Member Please specify which family member(s): I have read and understand the above informationPlease type your full name: Please sign:Date: MM slash DD slash YYYY
