PATIENT REGISTRATION FORM

Which of our clinics did you visit for your initial consultation?

MosmanNepean

Patient Details

First Name *

Last Name *

Preferred Name *

Date of Birth *

Gender

MaleFemaleNon-binary

Reason for Consult

How did you hear about us? *

Please explain "Other" as your choice above *

Contact Details

Best Contact Phone Number *

Email

Street address *

City *

State *

Postcode *

Emergency Contact Details

Name *

Street address *

City *

State *

Postcode *

Best Contact Phone Number *

Email

Next of Kin Contact Details

Is the next of Kin same as your emergency? *

YesNo

Next of Kin - Name

Next of kin - Email

Next Of Kin Phone

Referrer Details

Referring Doctor Or Optometrist Name

Clinic Name

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Clinic Name

Optometrist Name (if not referrer)

Clinic Name

Medicare

Do you use a different name in your medicare card? *

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No.

Expiry

Medicare Address (if different to your residential address)

Private Health Insurance

Do you have private Medical insurance *

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, or healthcare card *

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

Medical and Eye History

Please list any previous eye conditions or surgeries

Please list any medications you take

Please list any allergies

Ocular Surface Index

Ocular Surface Index result (for clinic use only)

Number of ocular surface index questions answered 0-12 (for staff)

If you experience dry eyes, how long have you had symptoms for?

Ocular Surface Index Score

Based on your responses to the ocular surface index questions, our team will be able to determine your ocular surface index. This gives us important information regarding your eye health and helps unmask any issues with dry eyes that may need treating.

Dry Eye Severity

Normal MildModerateSevere

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

I confirm that I would like to receive updates on clinic news and promotions by email (can unsubscribe any time).

Patient/ Guardian Signature *

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Date *

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