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


    *First name:

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

    Street address 2:

    *Suburb: *Post Code:

    Postal address

    *Street address:

    Street address 2:

    *Suburb: *Post Code:


    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


    Relationship to you:


    Contact phone:


    *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:


    Who is your usual GP?:


    Who is your usual optometrist?:


    *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:



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