Patient Information Form – Insight Eye Surgery

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

PERSONAL INFORMATION

Salutation:
*First name:

Middle name:

*Surname:

Known as:

*Sex:
Gender:
*Date of birth:
Marital status:
Occupation:

Country of birth:

Primary Language:

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

Street address 2:

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

Postal address

Same as residential 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?
YesNo

Your email address

*Do you consent to receive mobile SMS correspondence?
YesNo

Next of kin

Name:

Relationship to you:

Address:

Contact phone:

*Medicare

Yes, I have a Medicare cardNo, I do not have a Medicare Card (eg overseas visitor)

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

*Expiry date:

Month: Year:

Health fund details

*Do you have private health insurance?
YesNo

Health fund:

Membership number:

Customer number:

Position on card:

Department of Veteran Affairs details

*Do you have a DVA card?
YesNo

Dept. of Veterans Affairs card number:

DVA card colour:

Expiry date:

Pension Card details

*Do you have a Pension Card?
YesNo

Pension Card number:

Expiry date:

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

Health Care Card number:

Expiry date:

Work Cover details

*Is this a Work Cover Claim?
YesNo

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?
YesNo

Please list other specialists:

Past Ocular History
(select as appropriate)
Cataract surgeryRetinal surgeryAge-related macular degenerationDiabetic eye diseaseIntravitreal injectionsGlaucomaPterygium surgeryRefractive laser surgery (laser vision correction) for short sightednessRefractive laser surgery (laser vision correction) for long sightednessInherited retinal diseaseContact lens wearUveitisHigh myopiaOcular trauma/facial trauma
Other – please list:

Medical History
(even if you take medications for these conditions)
AsthmaDiabetesHeart DiseaseHigh cholesterolHypertension (high blood pressure)Pulmonary heart disease
Other – please list:

Family Ocular History
(select as appropriate)
Age-related macular DegenerationBlindnessGlaucomaInherited retinal disease
Other – please list:

*Do you currently take any medications?
YesNo

(select as appropriate)
AspirinAtacandAtenolol (Sandoz)CandesartanCavstatContraceptive pillCrestorDiabex (Metformin)DoxycyclineInsulinJardiametKarveaLipitorLyricaMicardisNEXIUMPanadolProliaRivaroxabanRosuvastatinTarginThyroxine/LevothyroxineVentolinXaraltoZoloft
Other – please list:

*Do you have any medication allergies?
YesNo

Please list allergies:

Please provide any other comments:

Upload your referral if you have one

INFORMATION PRIVACY

Checking the boxes below indicates you understand and accept that the information you submit will be stored, viewed and used according to our Privacy Policy. Please read this Privacy Policy carefully prior to signing.

I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed (including fax and email) by Insight Eye Surgery. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained.

I give permission for my personal information to be collected, used and disclosed as described above. I also give permission for Insight Eye Surgery to request my medical history from any public and private hospitals, general practitioners or specialist surgeries to assist in my medical treatment.

I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

PATIENT CONSENT

I understand that Insight Eye Surgery policy requires all patients to see a doctor for test results and whilst every effort will be made to contact patients with abnormal results, it cannot be assumed that test results are normal if there is no contact from our clinic.

I agree to pay all fees associated with my care at the time of consult.

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: