Combined Optometry and Dental Consent Form

MOBILEYES OPTOMETRY AND DENTAL

Student consent and Medical History Form
Which Mobileyes service are you registering for?*

Optometry (Eyes)Dental (Teeth)Both Optometry and Dental
1) Patient's Details

Note to parents/guardians: PLEASE ENTER YOUR CHILD'S NAME HERE
Patient's Name (As on Medicare Card)*

If patient only has 1 name as a legal name on their Medicare card, please type the same name in both the "First Name" and "Last Name" box.
Date of Birth*

DayMonthYear
Community Centre / School Name*
Community Centre / School Name*
If other please specify the Community Centre / School
Grade (If in school)
Class Name (If in school)
2) Medicare Details
Does the patient have a Medicare card?*

YesNo
Medicare Card Number (10 digits)*
Medicare Card Reference Number (to the left of patient's name*
Expiry Date (MM/YYYY) *
3) Parent/Guardian Contact Details
Parent / Guardian Name (If not the patient)
Address

Street Address

Suburb

CityState

Post Code
Phone number
Email (Please check spam if you do not receive the report or advise if you do not have an email address as all correspondence is via email)*
Needed to receive eye examination reports.
Email address (Please check spam if you do not receive the report or advise if you do not have an email address as all correspondence is via email)
example@example.com
4) Patient's Medical History

Information is for Optometrists' or Dentists' use only.
Is the patient receiving any medical treatment at present*

YesNo
If Yes, please provide details.
Does the patient have any serious or long standing illness?*

YesNo
If Yes, please provide details.
Does the patient take any MEDICATIONS (E.g. Epilim)*

YesNo
If Yes, please provide details.
Does the patient have any ALLERGIES? (E.g. Penicillin, Latex)*

YesNo
If Yes, please provide details.
5) Optometry (Eyes) History
When was the patient's last eye examination?*

NeverGreater than a yearWithin the last year
Does the patient currently wear glasses?*

YesNo
Does the patient report blurry vision, headaches, sore eyes, eye strain, double vision, or trouble concentrating?*

YesNo
If yes, please describe in detail, We will contact you prior to the visit if more information is needed.
Does the patient have a history of a history of eye injuries/surgery?*

YesNo
If Yes, please provide details below
Does the patient have a family history of eye disease (E.g. glaucoma)*

YesNo
If yes, please provide details below
6) Dental (Teeth) History
When was the patient's most recent visit to the dentist?*

NeverGreater than a yearWithin the last year
How is the patient's current oral health?*

GoodFairPoor
Does the patient have any of the following medical conditions? (Please tick if it applies)

Cardiovascular diseaseDiabetesLow Blood pressureHigh Blood pressureMusculoskeletal problemsAutoimmune disordersExcessive bleedingGastriointestinal problemsRheumatic feverUrogental problemsThyroid problemsInfectious diseasesNervous system problemsCurrently pregnantEpilepsyAnxietyPrevious head injuriesProsthetic implantsOrthodonticsBronchitisEmphysemaAsthmaOther respiratory illnessRecent surgeryChemotherapyRadiation therapy
Please use this area to write additional notes if needed. We will contact you prior to the visit if more information is needed.
7) Optometry Consent
Medicare Consent*

I hereby authorise and consent for MOBILEYES and their licensed Optometric staff to conduct a comprehensive BULKBILLED eye examination on my child and, if needed, to prescribe and dispense eyewear. I am hereby authorising FULL disclosure of the results of my child’s vision exam This information may be shared only with the following parties: Myself, My child’s school and LegalGuardians
I consent to the patient having their photo taken when selecting frames?*

YesNo
Private Test (No Medicare)

Please pay Mobileyes Optometry $50.00 if your child does not have a valid Medicare card via BANK TRANSFER with the details provided. Please use your child's name as the reference.
- Account Name: Mobileyes Optometry
- BSB: 062-124
- Account Number: 1175-0716
NSW Spectacles Program

The NSW Spectacles Program provides free glasses and vision aids to financially disadvantaged NSW residents.

Eligibility
Your child may be eligible for free glasses if:
- of Aboriginal or Torres Strait Islander descent
- you are an Australian permanent resident living in NSW receiving a full Centrelink pension or income support payment, and receive no other income other than the Centrelink payment, or
- you are a low-wage earner who earns less than:
  - the full JobSeeker Payment if you're aged under 65, or
  - the aged pension if you're aged 65 or over.
  - have financial assets less than $500 (if single) or $1,000 (if married/partnered or parent/guardian)
  - are a DVA cardholder who is not eligible to receive subsidised glasses through the Department of Veteran Affairs
If you wish to apply for spectacles through the NSW Spectacles Program, please submit your Centerlink Reference Number (CRN) in the field below:
Do you wish to apply for spectacles through the NSW Spectacles Program? If yes please input parent/guardian Date of Birth and CRN Number and Letter*

YesNo
Parent/Guardian Date of Birth

MonthDayYear
Date
Centerlink Reference Number (CRN - Not including the letter)
Letter at the end of the Reference Number
Is the patient of Aboriginal or Torres Strait Islander descent? (this question determines eligibility for free glasses)*

YesNo
8) Dental Consent
Medicare and Child Dental Benefit Scheme (CBDS) consent - Please tick all*

I give consent to check my child's Medicare-CDBS eligibility on my behalf.If eligible for CDBS, I give consent, for my child to receive dental treatment which includes Comprehensive Oral Examination, Cleaning (removal of calculus or plaque), X-rays, Fluoride application and Fissure Sealants; to be carried out by MOBILEYES School Dental Program practitioners (Bulk-billed; NO GAP payable).I give consent to provide further treatment which may be required such as dental fillings, also Bulk-billed; NO GAP payable (if eligible) for CDBS.If your child DOES NOT have a valid Medicare card, or is not eligible through the Child Dental Benefit Schedule, please pay Mobileyes $99.00 via bank account details provided below. Please use the child's name and school as reference.
- Account Name: Mobileyes Dental
- BSB: 062-123
- Account Number: 1084-8351
Child Dental Benefit Schedule - Bulk Billing Consent - Please tick all*

I, the parent/legal guardian, certify, that I have been informed of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule. The likely cost of this treatment; and that I will be bulk billed for services under the Child Dental Benefits Schedule and that I will not pay out-of-pocket costs, subject to sufficient funds being available under the benefit cap.I understand that I / the patient will only have access to dental benefits of up to the benefit cap and that the benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule. I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.
9) Consent!
The information provided above may be shared with appropriate governmental health care authority, and or/with Medicare to check or assess the oral health service your child has received and how these services were provided. We won't use your child's personal details in any publication however we may use your child's photograph on our print and/or electronic media platforms for marketing purposes only.
By signing below, you give consent for us to provide the services mentioned above.*

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MOBILEYES OPTOMETRY AND DENTAL

1) Patient's Details

2) Medicare Details

3) Parent/Guardian Contact Details

4) Patient's Medical History

5) Optometry (Eyes) History

6) Dental (Teeth) History

7) Optometry Consent

8) Dental Consent