Patient Details & Consent 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

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?

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) *

Date

Time

Patient Details & Consent Form

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