New Patient form

If you are new to our practice, please complete the below form before your first appointment.

If you prefer, you are welcome to complete the form in practice. Please arrive at least 15 minutes prior to your appointment.

New Patient Form

Medicare Details

Please enter your name exactly as it appears on your medicare card

Title

Medicare Number

First Name

Medicare Reference Number

Last Name

Medicare Expiry Date

Personal Details

Street Address

Suburb

State

Postcode

Phone Number

Email Address

Gender (optional)

Date of Birth

Occupation

Do you have a Concession or Pension Card?

Yes

Concession or Pension Card Expiry Date

Concession or Pension Card Number

Do you have Private Health Insurance for Optical Extras?

Yes

Private Health Fund Provider

Main reason for visit

Lifestyle Details

It is important for us to understand how you live your life in order to provide you with a tailored eyewear solution to suit your needs and lifestyle. Please answer the questions below to give us an insight into yours.

Do you currently wear glasses?

Yes

How old is your current pair of glasses?

Do you have more than 1 pair of glasses?

Yes

Do your glasses feel heavy on your face at the end of the day?

Yes

Do you currently wear contact lenses?

Yes

Are your eyes comfortable at the end of the day?

Yes

Are you interested in trialling contact lenses?

Yes

Do you spend a lot of time outdoors?

Yes

Do you have a problem with glare?

Yes

Do you wear prescription sunglasses?

Yes

Do you require safety glasses for your occupation or sporting activities?

Yes

Does your work require computer use?

Yes

Do you have a dedicated pair of computer/office spectacles?

Yes

How long do you spend per day on computers or other screen based devices?

Less than or equal to 2 hours

More than 2 hours

Do you experience one or more of the following after extended use? (check all that apply)

Eye fatigue

Headaches

Dry, sore or blurred eyes

Neck or shoulder pain

Hobbies, sports and special interests

Medical Details

Since many general health conditions can be associated with eye health conditions it is important for us to have a clear understanding of your medical health and family history. Please select all that apply below

Medical Conditions

Any other medical conditions

Other

Other explanation

Referrer's Name

Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email and sms?

Yes

Which of our practices are you attending?

Ringwood (Eastland Shopping Centre)

Croydon

Healesville

Yarram

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	Personal History	Family History
Allergies
Cancer
Cataracts
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About

About Us

Our Team

Pricing

Frequently Asked Questions

Eye Checks

Comprehensive Eye Test

DNEye

Dry Eye Test

Myopia Test

OCT

Diabetes Eye Check

Visual Field Test

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Eye Health

Cataracts

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Macular Degeneration

Diabetes Eye Checks

Eye Treatments

Dry Eye Treatment

Eye Infection Treatment

Amblyopia (Lazy Eye) Treatment

Myopia Treatment

View All Eye Treatments

Eyewear

Glasses

Contact Lenses

Locations

Ringwood

Croydon

Healesville

Yarram

Contact Us

New Patient form

Medicare Details

Personal Details

Lifestyle Details

Medical Details

Other

Ringwood (Eastland)

Croydon

Healesville

Yarram

Which location would you like to attend?

Ringwood

Croydon

Healesville

Yarram