Patient Details & Consent - On Line Form

Title *

Please fill out this questionnaire carefully and submit it before your next appointment. The information supplied will allow for a more efficient use of time. If you have any questions or concerns prior to your appointment, please do not hesitate to contact us.

Patient Name *

First

Last

Preferred Name *

Date of Birth *

Photo of Patient

Click or drag a file to this area to upload.

Parent/Guardian/Carer's Name (if applicable and for Patient's under 18)

First

Last

Emergency Contact *

First

Last

Emergency Contact Mobile Phone *

Emergency Contact Relationship to Patient (eg husband, mother, sister) *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Mobile Phone *

Email *

Email

Confirm Email

Occupation

Name of School (if patient is of school age)

GP Name or Medical Centre

Do you have a Private Health Fund? *

Yes
No

Private Health Fund Name

Does your cover include Extras?

Yes
No

Medicare Number *

Patient Reference Number on Medicare Card *

Expiry Date *

Are your bank details registered with Medicare?

Yes
No

Please select if you have any of the following cards:

Which are your preferred method/s of communication?

SMS
Email
Post

Please tick if you DO NOT want to receive the following communication?

Appointment reminders
Glasses pickup
Updates to practice operations
Eye health information
Patient specific relevant promotions (eg quarterly newsletter)

Hobbies and Lifestyle

How did you hear about our practice?

Do you have a family history of any eye diseases?

Do you have any known eye diseases?

When was your last eye test? *

Do you have any medical conditions?

What medications do you take?

Signature (Please type name) *

Patient Details & Consent – On Line Form

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