SSI Clinic Patient Information Form

SAVE SIGHT INSTITUTE
SAVE SIGHT INSTITUTE CLINIC PATIENT INFORMATION FORM
South Block, Sydney Eye Hospital, 8 Macquarie Street, SYDNEY NSW 2000

Tel: (02) 9382 7300

Email: ssi.clinic@sydney.edu.au

www.sydney.edu.au/save-sight-institute
PERSONAL DETAILS
TITLE *

MR MRS MISS Other
Name

FIRST NAME SURNAME
KNOWN AS
DATE OF BIRTH

Month Day Year
Date
RESIDENTIAL ADDRESS

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CONTACT PREFERENCES
Pref 1: PHONE NUMBER
Pref 2: PHONE NUMBER
Pref 3: PHONE NUMBER
CAN WE CONTACT YOU via SMS?

YES NO
E-MAIL
example@example.com
CAN WE CONTACT YOU via EMAIL?

YES NO
WOULD YOU LIKE TO BE PUT ON THE SSI NEWSLETTER LIST?

YES NO
FINANCIAL DETAILS
MEDICARE CARD No.
Ref.
Exp.
PENSION CARD / HEALTHCARE CARD
No.
Exp.
ARE YOU FINANCIALLY DEPENDEDNT?
Page 1 of 2 Your personal information will not be used for any purpose other than that for which it is collected unless it is authorised or required by law, you have given us consent to do so or its use meets one of the other exceptions under the Information Privacy Principles. To view our full privacy policy please ask reception.
SSI Clinic Patient Details Form

ALTERNATIVE/EMERGENCY CONTACTS

If the patient is under 18 years of age, please ensure to provide both parents/guardian details. All patients must have at least one person noted for emergency contact purposes.
PERSON 1

o ALL MATTERS o EMERGENCY ONLY o ALL MATTERS o EMERGENCY ONLY o ALL MATTERS o EMERGENCY ONLY PREFERRED PRACTITIONER DETAILS o Send ALL correspondence updates PERSON 3 o Send ALL correspondence updates o Send ALL correspondence updates OTHER INFORMATION

FULL NAME

	PERSON 1	PERSON 2	-
CONTACT NUMBER(S)
RELATIONSHIP
TYPE OF CONTACT

Full name and practice details required.
o Send ALL correspondence updates
OTHER
o Send ALL correspondence updates
o Send ALL correspondence updates
Please note any other special needs or information you wish for us to be aware of.
Page 2 of 2 Your personal information will not be used for any purpose other than that for which it is collected unless it is authorised or required by law, you have given us consent to do so or its use meets one of the other exceptions under the Information Privacy Principles. To view our full privacy policy please ask reception.
Should be Empty:

SAVE SIGHT INSTITUTE

SAVE SIGHT INSTITUTE CLINIC PATIENT INFORMATION FORM

PERSONAL DETAILS

CONTACT PREFERENCES

FINANCIAL DETAILS

PENSION CARD / HEALTHCARE CARD

ARE YOU FINANCIALLY DEPENDEDNT?

OTHER