Patient Details & Consent Form Please enable JavaScript in your browser to complete this 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 *FirstLastPreferred Name *Date of Birth *Parent/Guardian/Carer's Name (if applicable and for Patient's under 18)FirstLastResidential Address *Postal AddressPlease type As Above if Postal Address is the same as Residential AddressHome PhoneWork PhoneMobile Phone *EmailEmailConfirm EmailOccupationName of School (if patient is of school age)GP Name or Medical CentreDo you have a Private Health Fund? *YesNoPrivate Health Fund NameDoes your cover include Extras?YesNoMedicare Number *Patient Reference Number on Medicare Card *Expiry Date *Are your bank details registered with Medicare?YesNoPlease select if you have any of the following cards:Pension Concession CardHealth Care CardDepartment of Veteran Affairs Gold CardSeniors Health Care CardSeniors CardHobbies and LifestyleHow did you hear about our practice?Please tick if you DO NOT want to receive the following communication?Appointment remindersGlasses pickupUpdates to practice operationsEye health informationPatient specific relevant promotions (eg quarterly newsletter)Which are your preferred method/s of communication?SMSEmailPostDo you have any known eye diseases?Do you have a family history of any eye diseases?Do you have any medical conditions?What medications do you take?When was your last eye test? *Signature (Please type name) *Date *WebsiteSubmit
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