Kiddies Eye Care Yarraville- Adult Pre-Examination Form

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

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

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 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.

Additionally we are a private billing practice and payment is required at time of consultation. Eligible Medicare card holders will receive a rebate into their account.

Please call us on (03) 9448 8933 for further clarification of fees.

Signature

Date