New Patient Information

Thank you for booking with us. Before your appointment please take the time to fill in this form so we know how to best help you.

If completing this form for a dependant please provide Parent/Guardian Name and Date of Birth. (required for medicare claims)


Additional Information



Medical HistoryYouRelative

(select all that apply)

Vision Requirements Have Interested In

(select all that apply)

Do you experience...

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Please complete if your child is under 16 years of age

Signs of poor visual efficiency

Does your child show signs of/complain of:

Signs of visual processing difficulties

Does your child show signs of/complain of:

Additional History Yes No

(select all that apply)

PRIVACY STATEMENT: Our practice respects your privacy & will comply with the Privacy Act & Australian Privacy Principles when handling your personal information. The information provided on this form helps us to make informed decisions on how to best meet your eyecare and eyewear needs. We may use your personal contact information to send you information regarding eye health, eyecare and eyewear, with your consent. We may also need to provide some personal information to third party suppliers (such as mail-out and electronic distribution services & 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.