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.
Date of Birth

DayMonthYear
Date
Gender

MaleFemaleNon BinaryPrefer not to say
Personal Pronouns
Do you identify as Aboriginal or Torres Strait Islander Origin?
Brief Summary of any eye or vision concerns
Date and place of last eye exam
Brief Health History

High blood pressureDiabetesThyroid issuesConcussionDiabetesHeadaches/migrainesOther
Other
Current Medications
Allergies
How did you find us?

Word of mouthGoogleReferral
Do you consent to anyone acting on your behalf?

YesNo
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.
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Date

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Date
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