Patient Registration

"*" indicates required fields

DD slash MM slash YYYY
Sex:*
(Card must be given to front desk)
(Please list)
(must list FIRST and LAST name)
optometrist or ophthalmologist
Do you wear contact lenses?*
(Past or Present)
Do you have diabetes?*
Do you have high blood pressure?*
Do you have thyroid disease?*
Do you have a pacemaker?*
Do you have aids or HIV?*
Do you smoke?*
Do you have asthma?*
Do you have pulmonary (lung) disease?*
Are you pregnant? Please inform the doctor and staff.*
Have you taken Accutane?*
(acne/skin medication)
Are you prone to fainting or feeling light-headed?*
Do you have any allergies to medications or shellfish?*
I, the undersigned, authorize Dr. Karim G. Punja and/or Dr. Chirag Shah, to release medical records to my referring physician or optometrist. I also hereby give permission for Dr. Karim Punja and/or Dr. Chirag Shah to use my photographs for the purpose of patient information, clinic advertisements and for the purpose of training physicians.
I also give consent to Karim G. Punja Professional Corporation, its Associates and Dr. Chirag Shah to access my medical information on Alberta Netcare for the purpose of providing me with the best possible level of care.
DD slash MM slash YYYY