New Patient Details Form |

Step 1 of 14

Patient Details

Prefix(Required)

Gender(Required)

Type "Nil" if not applicable

Date of Birth(Required)

MM slash DD slash YYYY

Name(Required)

First Middle Last

Your physical addresses

My residential address is same as my postal address(Required)

Yes

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How we can reach you

Home Phone

Type "Nil" if not applicable

Mobile(Required)

Email(Required)

Clinical Details

Do you have allergies?(Required)

Yes

Allergies (press + to add)

Are you taking any medication including supplements?(Required)

Yes

Medications and Supplements (press + to add)

What is your occupation?(Required)

Retired

Working

Occupation

Clinical Details 2

Do you have glasses?(Required)

Yes

Reasons you wear glasses

Multifocal/Progressive

Bifocal

Distance

Reading

Do you drive?(Required)

Yes

Do you have history of:

None

Asthma

Heart Disease

Stroke

Diabetes

Hypertension

Multiple Sclerosis

Have you had any of the following eye procedures or conditions?

None

Cataract Surgery

Macular Degeneration

Laser Treatment

Glaucoma

Eye Trauma

Fuchs Endothelial Dystrophy

Other

Other eye procedures or conditions

Does anyone in your family have the following eye conditions?

None

Glaucoma

Fuchs Endothelial Dystrophy

Macular Degeneration

Other

Other eye conditions in your family

Do you give consent to receive appointment reminders via text and email?(Required)

Yes

Medicare Details

Do you have an Australian Medicare Card?(Required)

Yes

Medicare Card Number

Medicare Position Number

Medicare Expiry Date

Department of Veterans Affairs Details

Do you have a Department of Veterans Affairs Card?(Required)

Yes

Veterans Card Number

Veterans Card Expiry Date

Veterans Card Type

Veterans Card Condition

Private Health Fund Insurance Details

Do you have hospital cover?(Required)

Yes

Hospital Cover Fund Name

Hospital Cover Member Number

Consession Card Details

Do you have a Government Issued Centrelink?

Do you have Pension Card?(Required)

Yes

Do you have Health Care Card?(Required)

Yes

Pension Card Number

Pension Card Expiry Date

Health Care Card Number

Health Care Expiry Date

Next of Kin / Emergency Contact Details

Emergency Contact Name(Required)

Type "Nil" if not applicable

Emergency Contact Phone(Required)

Type "Nil" if not applicable

Emergency Contact Relationship(Required)

Type "Nil" if not applicable

Medical Practitioner Details

Optometrist Practice

Optometrist Name

General Practitioner Practice

Doctor Name

For Patients under 18 years of age

Are you under 18 years of age?

Yes

Parent / Guardian Name

Guardian Date of Birth

MM slash DD slash YYYY

Guardian Medicare Number

Guardian Medicare Position Number

Guardian Medicare Expiry Date

Work Cover Claim Details

Are you making a work cover claim?

Yes

Employer

Work Cover Contact Person

Work Cover Contact Number

Work Cover Insurer

Work Cover Claim Number

Injury Details

Date of Injury

MM slash DD slash YYYY

Please note that accounts will be sent directly to your employer or insurer for work cover claims

How did you hear about us?

How did you hear about us

Family

Friend

Optometrist

Other

Other sources of how did you hear about us

NEW PATIENT DETAILS FORM

Patient Details

Your physical addresses

How we can reach you

Clinical Details

Clinical Details 2

Medicare Details

Department of Veterans Affairs Details

Private Health Fund Insurance Details

Consession Card Details

Do you have a Government Issued Centrelink?

Next of Kin / Emergency Contact Details

Medical Practitioner Details

For Patients under 18 years of age

Work Cover Claim Details

How did you hear about us?