Combined Optometry and Dental Consent Form

  • MOBILEYES OPTOMETRY AND DENTAL

    Consent and Medical History Form
  • Which Mobileyes service are you registering for?*

  • 1) Patient's Details

    Note to Parents/Guardians: PLEASE ENTER THE CHILD OR ADULT'S NAME HERE
  • Date of Birth*
     - -
  • Patient has previously attended a Mobileyes optometry or dental clinic:*

  • If YES, you may skip to 7) Optometry Consent

    However, please provide us with any new or updated information since our previous clinic

  • If YES, you may skip to 8) Dental Consent

    However, please provide us with any new or updated information since our previous clinic

  • 2) Medicare Details

  • Does the patient have a Medicare card?*
  • Image field 19

  • 3) Parent/Guardian Contact Details

  • 4) Patient's Medical History

    Information is for Optometrists' or Dentists' use only.
  • Is the patient receiving any medical treatment at present*
  • Does the patient have any serious or long standing illness?*
  • Does the patient take any MEDICATIONS (E.g. Epilim)*
  • Does the patient have any ALLERGIES? (E.g. Penicillin, Latex)*

  • 5) Optometry (Eyes) History

  • When was the patient's last eye examination?*
  • Does the patient currently wear glasses?*
  • Does the patient report blurry vision, headaches, sore eyes, eye strain, double vision, or trouble concentrating?
  • Does the patient have a history of eye injuries/surgery?*
  • Does the patient have a family history of eye disease (E.g. glaucoma)*

  • 6) Dental (Teeth) History

  • When was the patient's most recent visit to the dentist?*
  • How is the patient's current oral health?*
  • Does the patient have any of the following medical conditions? (Please tick if it applies)

  • 7) Optometry Consent

  • I consent to the patient having their photo taken when selecting frames?*

  • Private Test (No Medicare)

    Please pay Mobileyes Optometry $60.00 if your child does not have a valid Medicare card via BANK TRANSFER with the details provided. Please use your patient'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
    Patient 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*
  • Parent/Guardian Date of Birth
     - -
  • Is the patient of Aboriginal or Torres Strait Islander descent? (this question determines eligibility for free glasses)*

  • 8) Dental Consent

  • I give consent to Mobileyes to apply Flouride to patient's teeth during the dental service:*
  • Medicare and Child Dental Benefit Scheme (CBDS) consent - Please tick all*
    • Account Name: Mobileyes Dental
    • BSB: 062-123
    • Account Number: 1084-8351
  • Child Dental Benefit Schedule - Bulk Billing Consent - Please tick all*

  • 9) Payment Acknowledgement (If Not Eligible for Medicare/CDBS)


    I understand that if I or my child is not eligible for Medicare or the Child Dental Benefits Schedule (CDBS), I agree to pay the applicable fees for services provided by Mobileyes & Dental as follows:

  • Eye examination: $60*
  • Glasses (if required): $129*
  • Dental check (child): $110*
  • Dental check (adult): $149*

  • I acknowledge that I will be informed of eligibility prior to treatment where possible and accept responsibility for payment if services proceed without eligibility.

  • 10) 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 the patient has received and how these services were provided. We won't use the patient's personal details in any publication however we may use the patient's photograph on our print and/or electronic media platforms for marketing purposes only.

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