New Patient Registration Form - Insight Eye Surgery

Why are you attending Insight Eye Surgery?

CataractEye LaserRefractive Lens ExchangeDry Eye ClinicPterygiumGlaucomaOther Eye Condition

Questions marked with * are mandatory

PATIENT INFORMATION
Salutation:
*First name:

Middle name:

*Surname:

Known as:

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

Country of birth:

Primary Language:

Are you of Aboriginal and/or Torres Strait Islander origin?
YesNo
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:

Work Cover details

*Is this a Work Cover Claim?
YesNo

Work Cover Claim number:

YOUR MEDICAL HISTORY

What is your weight in kg?

What is your height in cm?

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:

Have you been under the care of a previous ophthalmologist? If so, please list below:
YesNo

Please list previous ophthalmologist:

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:

Are you pregnant?
YesNoN/A

Are you breastfeeding?
YesNoN/A

Are you currently undergoing any fertility or IVF treatment?
YesNoN/A

Family Ocular History

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

Do you take any of the following medications?

(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:

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.

Privacy and consent acceptance are ALL required to be ticked to be able to submit this form.

I have read the Privacy Policy and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed (including via AI scribes that may be used during the consult) by Insight Eye Surgery. I understand that if my information is to be used for any purpose other than that set out in the Privacy Policy, my further consent will be obtained.
I give permission for my personal information to be collected, used and disclosed as described in the Privacy Policy. 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 clinical actions to be undertaken in accordance with the Privacy Policy 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.

If you do not wish to accept these then please contact us directly.

*Please sign your signature in the box below and then press SUBMIT:

Please confirm all your details are correct, consent has been ticked and then submit your form by pressing the submit button below: