Registration Form

Do you have a confirmed appointment?(Required)

Yes

No

To complete the new patient registration form you must have an confirmed appointment.

To request an appointment please click here

Personal Information

Patient surname(Required)

Patient Given /Name(Required)

As printed in your Medicare Card

Date of birth

Sex

Male

Female

Address(Required)

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

Telephone

Emergency Contact/accompanying person(Required)

Prefix First Last

Emergency telephone(Required)

Email address(Required)

Email communication confirmation

Yes

No

Please confirm that you are happy to receive communication by email

Patient's Medicare

Patient's Medicare Number(Required)

Patient's Medicare Reference number(Required)

The number beside the patent's name

Patient's Medicare Expiry Date(Required)

MM/YYYY

Health insurance

Do you have private health insurance with hospital cover?

Yes

No

Insurance fund

Member Number

Referring Doctor's/Optometrist Details

Referring Doctor/Optometrist Name

Clinic Name

Clinic Address

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

Clinic Contact Number

Local GP and Clinic Details

Local GP name and Clinic Details

Same as Referring Doctor

Different to above

Local GP's Full Name

GP Clinic Name

Clinic Address

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

GP Clinic Contact Number

Family Medical History

Is there any eye disease that runs in the family?

Yes

No

Please provide details of the eye disease(s).

Details of any other relevant eye problems

Privacy, photography and consent

Privacy Statement

The information provided on this form is collected for the purpose of providing comprehensive Healthcare, this information will be retained on the patient record and kept confidential. The Patients record may however be disclosed to a third party involved in the care and under certain circumstances – where required by law or when requested by another medical practitioner/hospital including emergency medical care

Clinical Photography

Photographs or videos may be taken to record clinical findings. These may be used for:

Documenting your medical history
The teaching of health professionals and students studying healthcare here and in other hospitals/colleges/universities
The education of patients with conditions similar to yours. If publication in medical and scientific journals or textbooks is considered you will be contacted to obtain specific written permission.

Financial Consent

I understand that I will incur out of pocket expenses and that the fees are due and payable on the day of consultation.

Note: minimum 24hrs notice required for cancellation or non attendance, otherwise a cancellation fee applies.

Please tick the box below to confirm you have read and understood the privacy statement/photograph and financial consent

Patient consent(Required)

I understand and agree to the privacy statement, agree to Clinical Photography and provide my financial consent.

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