Please enter your personal, contact and health information below and then submit. Fields marked * are mandatory.

    PERSONAL INFORMATION

    Salutation:
    *First name:










    Residential address
    (please note we cannot accept PO Box addresses)
    *Street address:

    Street address 2:

    *Suburb: *Post Code:
    *State:
    *Country:

    Postal address

    *Street address:

    Street address 2:

    *Suburb: *Post Code:

    *State:
    *Country:

    Contact information

    *Preferred method of contact:
    Home phone:

    Mobile phone:

    Work phone:

    *Do you consent to receive email correspondence?

    Your email address

    *Do you consent to receive mobile SMS correspondence?

    Next of kin

    Name:

    Relationship to you:

    Address:

    Contact phone:

    *Medicare

    *Medicare number (the 10 digit number on your card):
    *Reference number:

    *Expiry date:

    Month: Year:

    Health fund details

    *Do you have private health insurance?

    Health fund:

    Membership number:

    Customer number:

    Position on card:

    Department of Veteran Affairs details

    *Do you have a DVA card?

    Dept. of Veterans Affairs card number:

    DVA card colour:

    Expiry date:

    Pension Card details

    *Do you have a Pension Card?

    Pension Card number:

    Expiry date:

    Health Care Card details
    *Do you have a Health Care Card?

    Health Care Card number:

    Expiry date:

    Work Cover details

    *Is this a Work Cover Claim?

    Work Cover Claim number:

    YOUR MEDICAL HISTORY

    Who is your usual GP?:

    Clinic/suburb:

    Who is your usual optometrist?:

    Clinic/suburb:

    *Are there any additional medical specialists you would like to have copied on correspondence?

    Please list other specialists:

    Past Ocular History
    (select as appropriate)

    Other – please list:

    Medical History
    (even if you take medications for these conditions)

    Other – please list:

    Family Ocular History
    (select as appropriate)

    Other – please list:

    *Do you currently take any medications?

    (select as appropriate)

    Other – please list:

    *Do you have any medication allergies?

    Please list allergies:

    Please provide any other comments:

    INFORMATION PRIVACY

    PATIENT CONSENT

    Please sign your signature in the box below:

    Privacy and consent acceptance are all required to be ticked to be able to submit this form. If you do not wish to accept these then please contact us directly.

    Please confirm all your details are correct and then submit your form by pressing the submit button below: