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Brampton Vision Centre
Call: 888-981-9724

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in Brampton

Mississauga Vision Centre
Call: 888-658-5141

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in Mississauga

 

Home » Patient Registration Form

Patient Registration Form

  • (please list ALL current medications including eye drops, injections, and health devices that you are currently using.
    This includes prescription and non-prescription items.)
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  • (please check any conditions which apply to you)
  • (please check any conditions which apply to you)
  • (please check any conditions someone in your family has had and note the relationship below)
  • ConditionRelationship 
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  • PATIENT PRIVACY PROTECTION FORM


    NOTE TO PATIENT: We want your informed consent. This means that we want you to understand the services we will provide you, and what we do with the personal information we obtain from you. If you have a question on any of this, please ask.
  • CONSENT FOR PERSONAL INFORMATION


    I understand that to provide me with optometric services and products, Mississauga Vision Centre Inc. and Brampton Vision Centre will collect some personal information about me (e.g. home telephone number, address, OHIP number, medications used).

    I know that at any time, I can request to review Mississauga Vision Centre Inc.’s and Brampton Vision Centre Inc.’s Privacy Policy with respect to the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information. I have been given a chance to ask any questions I have about the Privacy Policy and how it applies to me.

    I understand that I may receive without request, some of the following notices and information. If I do not want to receive some of this information, I agree to advise Mississauga Vision Centre Inc. and Brampton Vision Centre Inc.’s of my refusal in writing:
    • Notice when it is time to review my eye and vision care needs, including reminder notices for another eye examination
    • Newsletters and other informational mailings from Mississauga Vision Centre Inc. and Brampton Vision Centre Inc.
    • Notice of promotions and special offers from Mississauga Vision Centre Inc. and Brampton Vision Centre Inc.

    I understand that, as explained in the Privacy Policy, there are some rare exceptions to these commitments.

    I agree to Mississauga Vision Centre Inc. and Brampton Vision Centre Inc. collecting, using and disclosing personal information about me as set out above and in Mississauga Vision Centre Inc.’s and Brampton Vision Centre Inc.’s Privacy Policy.