03 9792 3077

New Patient Information

Thank you for booking with us. Before your appointment please take the time to fill in this form so we know how to best help you.

*Required
Mr   Mrs   Miss   Master  

Medical History

You

Relative

You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  Relative  
You  
You  
You  
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You  
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only required if completing the form for a minor

Do you have, or are you interested in having:

 

Have

Interested in

Have  Interested In  
Have  Interested In  
Have  Interested In  
Have  Interested In  
Have  Interested In  
Have  Interested In  

Do you experience...

yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  

Please complete the following if your child is under 16 years of age

Signs of poor visual efficiency

Does your child show signs of/complain of:

yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  

Signs of visual processing difficulties

Does your child show signs of/complain of:

yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
yes  
Yes   No
Reading
Writing
Spelling
Maths
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
I acknowledge that I have read and agreed to the privacy statement below  *
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PRIVACY STATEMENT: Our practice respects your privacy & will comply with the Privacy Act & Australian Privacy Principles when handling your personal information. The information provided on this form helps us to make informed decisions on how to best meet your eyecare and eyewear needs. We may use your personal contact information to send you information regarding eye health, eyecare and eyewear, with your consent. We may also need to provide some personal information to third party suppliers (such as mail-out and electronic distribution services & 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.