New Patient Form Welcome to Armstrong & Small Eye Care Centre! If you are a new patient, please fill out the form below. Returning patients may fill out the form to inform us of any changes.Patient Name First Middle Last Patient Date of Birth Parent/Guardian Name (if under 18)Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary PhoneMobileHomeWorkSecondary PhoneMobileHomeWork I give A&S permission to contact me via text E-mail address I give A&S permission to contact me via e-mail When was your last complete eye exam?1 year or less2 year or lessmore than 2 yearsPlease check the boxes below if you have any of the following conditions: Glaucoma Macular Degeneration Diabetes Retinal disease Do you wear contact lenses?YesNoWho may we thank for referring you? (optional)To help save our patients time and money, we direct bill with the following insurance companies. Please bring your insurance card to your appointment if you are insured by one of the following companies: Blue Cross Chambers of Commerce CINUP Cowan Insurance Group Desjardins (payable to patient only) First Canadian Great-West Life Green Shield GroupHEALTH GroupSource Industrial Alliance Johnson Inc. Johnston Group Inc. Manion Manulife Maximum Benefit Sun Life Financial Wawanesa Insurance Upload an image of your insurance cardWhile we are happy to submit a claim to your insurance on your behalf, we are unable to verify insurance benefits prior to your examination or eye wear purchase. We ask that you contact your insurance company in advance to confirm your eye care coverage and eligibility. Please note that certain plans for the above insurance providers do not allow direct billing, and in some cases, submission by the patient is required. Patients are responsible for any amount not covered by their insurance.