eye centre

Your Information
Title

MrMrsMsMissMasterDrOther
Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

DayMonthYear
Gender

MaleFemale
Do you identify as Aboriginal or Torres Strait Islander?

YesNo
If yes, are you registered for 'Closing the Gap PBS Co-Payment Program'?

YesNo
Address
Residential Address

Street Address

Street Address Line 2

CityState

Post Code
Postal Address (if different)
Contact Phone Numbers
Home
Mobile
Email
Do you agree to SMS appointment reminders?

YesNo
Next of Kin
Name
Relationship
Phone/Mobile
Do you consent to us discussing your appointments and care with your next of kin?

YesNo
Your occupation, or if retired, your previous occupation
Medicare & Cards
Medicare Number
Reference Number (next to your name)
Valid to
OR
DVA File Number
Type a question

Gold CardWhite Card
Card Expiry Date
Do you have a Pensioner Concession Card?

YesNo
Card Number (CRN)
Card Expiry Date
Do you have a Health Care Card?

YesNo
Card Number (CRN)
Card Expiry Date
Do you have private hospital insurance?

YesNo
Health Fund Name
Membership Number
TAMWORTH EYE CENTRE PRIVACY POLICY

(In respect of the person whose details are contained on this form, we request permission to manage and share relevant medical information with other relevant professionals and organisations when it is appropriate to do so.)

In accordance with the Privacy Act of December 2001, I hereby authorise any Hospital, Physician, Allied Health Professional or any other person who has attended the person named on this form to provide to Tamworth Eye Centre any and all information with respect to any sickness or injury, medical history, consultations, prescriptions or treatments and copies of all hospital or medical records. I agree that a photocopy of this authorisation shall be considered as effective and valid as the original.

I also authorise Tamworth Eye Centre to provide relevant medical information on request to any Hospital, Physician, Allied Health Professional, Insurance Company or Legal Practitioner on receipt of an authority signed by me or on my behalf.

I consent to clinical photographs being taken and used for educational purposes.

I agree for a letter to be sent to my referring medical practitioner or optometrist.
Signature
Medical History
Allergies?

YesNo
Please list any allergies
Please tick if you have any of the following conditions and list relative medications:

AnxietyDepressionArthritisAsthmaEmphysemaCancerDementia/AlzheimersParkinson's DiseaseMigraineDiabetes Type 1Diabetes Type 2Thyroid DiseaseHeart ConditionHigh Blood PressureHigh CholesterolStroke/Mini Stroke/TIAKidney DiseaseLiver DiseaseHIVHepatitisMRSA (Golden Staph)Hearing Impairment
Please list current medications
Please list previous operations
Eye Related Medical History
Do you have a history of eye problems?

Artificial EyeCataractCorneal GraftEye InfectionForeign BodyGlaucomaKeratoconusLaser TreatmentMacular DegenerationPterygiumRetinal DetachmentSquint
Do you use eye drops?

YesNo
Please list which eye drops:
Smoking Status

Never smokedPrevious SmokerCurrent Smoker
Year Ceased
Number Per Day
Alcohol Intake
Are you a non drinker?

Non Drinker
Number of alcoholic drinks per week
Social History
What is your status?

SingleDe FactoDivorcedMarriedSeparatedWidowed
Do you have a family history of the following?

AsthmaAutoimmune disordersCancerDiabetesDepressionGlaucomaHeart dieseaseHypertensionMacular degenerationStroke
Your General Practitioner or General Practice
Your regular Optometrist/Optometry Practice
Other specialists you attend
Should be Empty:

Your Information

Address

Contact Phone Numbers

Next of Kin

Medicare & Cards

OR

Medical History

Eye Related Medical History

Alcohol Intake

Social History