WELCOME TO OUR PRACTICE

Either fill in this form, or download and either bring it along to your appointment, fax it, or scan and email to us.

ADULT AND CHILDREN’S VISION: Glasses, Contact lenses, low vision and perceptual testing, vision training

An understanding of your medical history and information about your day to day activities will allow us to provide the highest quality eyecare and tailored solutions for your individual needs. We appreciate your time in completing this information.

Title:
Surname:
Given Names:
 Date of Birth:

Account/Contact Address:
Postcode:

  
Home Phone:
Work Phone:
Mobile:

Email Address:

Would you like to be included in our email newsletter list about health and practice issues?

 
If Child: BOTH PARENTS/GUARDIANS NAMES
General Practitioner name or practice name and location:
Health Care Card Holder
Veterans Affairs Gold Card
Private Health Fund Optical Extras

Fund Name:

 
OCCUPATION/SCHOOL:
I want a Report: ($20 subject to change without notice)

 

CURRENT MEDICATIONS (Prescription or over the counter)
PLEASE INDICATE IF YOU ARE CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS.
None Blood Pressure Antihistamines
Diuretics Heart Tablets Eye drops
Sleeping tablets Antidepressants Supplements
Specify:

 

MEDICAL HISTORY PLEASE ADVISE US IF YOU ARE OR HAVE SUFFERED ANY OF THE FOLLOWING
Eye Injury Lazy/Turned Eye Glaucoma
Allergies Heart Disease Eye Surgery
Cateracts Diabetes High Cholesterol
High Blood Pressure Regular flashing lights Headaches
Migraines Macular Degeneration    
Other please specify:

 

PLEASE ADVISE IF ANY OF YOUR FAMILY HAVE SUFFERED ANY OF THE FOLLOWING (and which family member)
Lazy/Turned Eye Glaucoma Allergies
Heart Disease Cateracts Diabetes
High Cholesterol High Blood Pressure Headaches
Migraines Macular Degeneration    
Other please specify:

 

HOBBIES, SPORTS, and SPECIAL INTERESTS? (please specify)

 

ARE YOU CURRENTLY WEARING SPECTACLES
Approximately how old are they?
ARE YOU CURRENTLY WEARING CONTACT LENSES?
Approximately how old are they?

 

Do You...  
Work at a computer for a long time?
Play Sport/Exercise Regularly?
Spend a lot of time outdoors?
Have any interest in contact lenses?
Have prescription sunglasses?
Have problems with glare or reflection particularly when driving at night?
Have more than 1 pair of glasses?
Like to change your look with different eyewear?
Would you be able to work without your glasses for a week or more?

 

WHY DID YOU CHOOSE OUR PRACTICE?
Friend Yellow Pages
Health care Practioner Current/Previous patient
Website    
If referred who may we thank?
       

PRIVACY STATEMENT
Please note that any information given here is held in the strictest confidence in accordance with National Privacy Principals.