Initial Consultation Form
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1Initial Consultation Form
Title: _____
First Name: _______________________
Preferred Name: ______________________
Surname:_________________________________
DOB:(DD/MM/YR) ______________________
Address:_____________________________________________________________________________
___________________________________________________
Post Code: ______________________
Email: _______________________________________________________________________________
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(Please tick here if you prefer not to be emailed for marketing purposes
Business Phone: ____________________________
Mobile: _________________________________
Occupation:___________________________________________________________________________
When was your last eye examination?__________________
Do you wear: Glasses?___________
Last Prescribed?____________
Contact Lenses? _________ Soft/Hard: _____________
Brand: _______________
Daily / 2 weekly / Monthly / Yearly ___________________________________
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If no, are you interested in contact lenses? Yes
No
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Are you interested in laser refractive surgery ? Yes
No
Do you suffer from Dry Eyes?____________________________________
List any concerns you have regarding your vision or eye health
_____________________________________________________________
Family history of eye disease?_____________
Glaucoma ________________________
Cataracts __________
Diabetes ___________
Other ____________________________
Have you ever injured your eyes or had surgery?_____________________________________
If yes, details: ________________________________________________________________
Indicate any current medications__________________________________________________
Indicate any allergies __________________________________________________________
What leisure activities do you participate in?_________________________________________
Retinal Photography and OCT Imaging (similar to an MRI of the retina) are used to detect eye diseases
earlier than most other diagnostic tests. They are an integral part of our eye examination but do NOT
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attract a Medicare rebate. Please indicate if you would like to discuss these tests further
How did you hear about our practice?
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Internet
Work Colleague
Friend/Relative
Walked Past
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GP
Optometrist
Live locally
Other _________________________
Privacy Statement:
Our practice respects your privacy and will comply with the Privacy Act and the National Privacy Principles
when handling your personal information. We use your information to help provide services to you, and to send you information
regarding eye health, eyecare and eyewear. If you do not provide this information requested in this form, we may be unable to
provide these services to you, or our ability to do so may be impaired. Please contact us if you would like to know more about how
we handle personal information.
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