For new adult patients, please fill in the form below Personal DetailsTitleNameGender Male Female Address(Required) Street Address City State Postcode Email(Required) PhoneMobileOccupationDate of birth DD slash MM slash YYYY Medicare number(Required)Card reference number(Required)Expiry Date(Required)Are you covered by Private Health Insurance(Required) Yes No Private Health Fund ProviderDo you have a Veteran Affairs Card? Yes No Do you have a Pension Card? Yes No GP's name(Required)GP's phone(Required)GP's addressPostcodeEmergency contact's nameEmergency contact's telephoneWhat's the reason for your visit today?Medical DetailsSince many general health conditions can be associated with eye health conditions it is important for us to have a clear understanding of your medical health and family history.Allergies Your History Family History Cancer Your History Family History Cataracts Your History Family History Diabetes Your History Family History Eye Injury Your History Family History Eye Surgery Your History Family History Glaucoma Your History Family History Heart Disease Your History Family History High Blood Pressure Your History Family History High Cholesterol Your History Family History Lazy Eye Your History Family History Macular Degeneration Your History Family History Retinal Disease Your History Family History Stroke Your History Family History OtherGeneral Eye Health DetailsIt is important for us to understand any possible indicators of an eye health condition. Understanding your current symptoms will help us to effectively treat and/or manage your overall eye health.Do you experience any of the following: Burning Eyes Itchy Eyes Gritty Eyes Watery Eyes Dry Eyes Sore Eyes Red Eyes Floaters/Spots in Vision Flashing Lights in Vision Double Vision Sensitivity to Light/Glare Eye Strain Headaches Reading Difficulties Lifestyle DetailsIt is important for us to understand how you live your life in order to provide you with a tailored eyewear solution to suit your needs and lifestyle. Please answer the questions below to give us an insight into yours.GLASSESDo you currently wear glasses?(Required) Yes No How old is your current pair?Do you have more than 1 pair of glasses? Yes No Do your glasses feel heavy on your face at the end of the day? Yes No CONTACT LENSESDo you currently wear contact lenses? Yes No Are your eyes comfortable at the end of the day? Yes No Are you interested in trialling contact lenses? Yes No OUTDOORS AND PROTECTIONDo you spend a lot of time outdoors? Yes No Do you have a problem with glare? Yes No Do you wear prescription sunglasses? Yes No Do you require safety glasses for your occupation or sporting activities? Yes No COMPUTERS AND SCREEN DEVICES Does your work require computer use? Yes No Do you have a dedicated pair of computer/office spectacles? Yes No How long do you spend per day on computers or other screen based devices? Less than 2 hours More than 2 hours Do you experience one or more of the following after extended use? Eye Fatigue Headaches Dry, sore or blurred eyes Neck or shoulder pain? Hobbies, Sports and Special InterestsPlease listHow did you hear about us?Please select Relative / Friend / Previous Patient Your GP Internet Search Our Website Facebook / Social Media Print Advert Other Future communicationAre you happy to receive occasional communications regarding eye health information and special offers by mail, email and sms? Yes No Thank you for entrusting us with your eyecarePrivacy Statement: Our practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide services to you. We may also use your personal contact information to send you information regarding eye health, eye care and eyewear, with your consent. By providing the information requested in the first three sections of this form we will be able to make an informed decision on how to best meet your eye care and eyewear needs. We may also need to provide some personal information to third party suppliers (such as providers of mail-out and electronic distribution services and eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy. I have ready and understood the privacy statement(Required) Yes CAPTCHA Δ
