Welcome to the Practice Form

Page 1

Welcome to our Practice

Thank you for choosing <practice name> for your eye health and eye care needs. Please complete the following:

GENERAL INFORMATION Title.

First Name.

Date of birth.

/

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Gender.

Surname. Male

Female

Occupation.

Address.

Postcode.

Home Tel.

Mobile.

Email.

DOCTOR INFORMATION Name.

Address.

Tel.

Postcode.

Medicare No.

Ref. No.

Private Health Fund.

Yes

No

Expiry.

Private Health Fund Provider.

When was your last eye examination?

LIFESTYLE

T F

Please list any hobbies, sports (incl. swimming) or special interests you have below. Do you require safety glasses for your occupation or sporting activities? Do you work on a computer?

Yes

Do you wear glasses?

Yes

No

Do you wear contact lenses?

Yes

No

Yes

No Please specify.

Do you wear prescription sunglasses?

If yes, what brand are they?

MEDICAL HISTORY

No

A R D If yes, how old are they?

No

Yes

Please indicate if you or your family have experienced any of the following:

Do you spend a bit of time outdoors?

If no, are you interested in contacts?

Eye Injury

Lazy Eye

Glaucoma

Cataracts

Eye Surgery

Heart Disease

Allergies

Diabetes

High Cholesterol

High Blood Pressure

Stroke

Macular Degeneration

Other? Please specify.

Yes

No

Are there any particular concerns or questions you have about your vision or eye health?

HOW DID YOU HEAR ABOUT OUR PRACTICE? Friends or relative? Name:

Yellow Pages

Previous patient? Name:

Yellow Pages Online

Health Care Practitioner? Name:

Newspaper Ad

Civic Group or Community Event? Which:

Radio Ad

Sporting Club? Which:

Other, please specify:

PRIVACY STATEMENT Our practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide services to you. We may also use your personal contact information to send you information regarding eye health, eye care and eyewear, with your consent. By providing the information requested in the first three sections of this form we will be able to make an informed decision on how to best meet your eye care and eyewear needs. We may also need to provide some personal information to third party suppliers (such as providers of mail-out and electronic distribution services and eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy.

CAN WE PROVIDE YOU WITH UPDATES ON EYE HEALTH, EYEWEAR AND SPECIAL OFFERS? Do you consent to us sending you occasional communications including appointment and check-up reminders, eye health information and relevant promotions via email, SMS or post? Yes to all of the above OR Yes, but please only contact me via: Email Signature.

SMS

Post Name.

Date.

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Welcome to the Practice Form by ProVision - Issuu