Kiddies Eye Care Geelong- Adult Pre-Examination Form

Kiddies Eye Care Geelong- Adult Pre-Examination Form

Please complete this form prior to your appointment and bring any current spectacles
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Personal Pronouns
Do you identify as Aboriginal or Torres Strait Islander Origin?
Do you currently wear glasses? Tick all that apply, or specify in othoer

Other
If you currently wear glasses how old is your current pair/pairs?

Other
Brief Summary of any eye or vision concerns
Date and place of last eye exam
Brief Health History. Tick all that apply.

Other
Brief Eye History. Tick all that apply

Other
Other. Please elaborate.
PLEASE NOTE: If you have had a concussion, Traumatic Brain Injury/Stroke or are experiencing double vision, Please let our friendly staff know as there is an additional form required for us to obtain further details to best assist with your care.
Current Medications
Allergies
How did you find us?
Do you consent to anyone acting on your behalf?
Please provide names of the people who can act on your behalf
Is there anything else you would like us to know?
Please note that by completing this form you consent to participating in an eye examination. Your eye examination may include, but may not be limited to the following tests: Visual acuity, to determine the need for glasses or a change in prescription for glasses or contacts, a binocular vision assessment and ocular health, these results will be documented in our medical records. At Kiddies Eye Care our priority is your eye health. Please notify the Optometrist if you do not wish to participate in a specified test.
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: