Combined Optometry and Dental Consent Form

MOBILEYES OPTOMETRY AND DENTAL

Consent and Medical History Form
Optometry (Eyes)Dental (Teeth)Both Optometry and Dental
1) Patient's Details

Note to parents/guardians: PLEASE ENTER THE CHILD'S OR ADULT'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 / Location*
If other please specify the Community Centre / School / Location
Grade/Year (If in school)
Class Name (If in school)
YESNO / NOT SURE
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
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.
YesNo
If Yes, please provide details.
YesNo
If Yes, please provide details.
YesNo
If Yes, please provide details.
YesNo
If Yes, please provide details.
5) Optometry (Eyes) History
NeverGreater than a yearWithin the last year
YesNo
YesNo
If yes, please describe in detail, We will contact you prior to the visit if more information is needed.
YesNo
If Yes, please provide details below
YesNo
If yes, please provide details below
6) Dental (Teeth) History
NeverGreater than a yearWithin the last year
GoodFairPoor
Cardiovascular diseaseDiabetesLow Blood pressureHigh Blood pressureMusculoskeletal problemsAutoimmune disordersExcessive bleedingGastriointestinal problemsRheumatic feverUrogental problemsThyroid problemsInfectious diseasesNervous system problemsCurrently pregnantEpilepsyAnxietyPrevious head injuriesProsthetic implantsOrthodonticsBronchitisEmphysemaAsthmaOther respiratory illnessRecent surgeryChemotherapyRadiation therapyNone of the above
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
I hereby authorise and consent for MOBILEYES and their licensed Optometric staff to conduct a comprehensive BULKBILLED eye examination on the patient and, if needed, to prescribe and dispense eyewear. I am hereby authorising FULL disclosure of the results of the patient's vision exam This information may be shared only with the following parties: Myself, the school/centre and Legal Guardians/centre's staff
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 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:
YesNo
Parent/Guardian Date of Birth

MonthDayYear
Date
Centerlink Reference Number (CRN - Not including the letter)
Letter at the end of the Reference Number
YesNo
8) Dental Consent
YESNO
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 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 my child DOES NOT have a valid Medicare card, or is not eligible through the Child Dental Benefit Schedule, I am willing to pay $99.00 for the dental service. This is to be paid via bank account details provided below. Please use the student's name and school as reference.
- Account Name: Mobileyes Dental
- BSB: 062-123
- Account Number: 1084-8351
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 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.
By signing below, you give consent for us to provide the services mentioned above.*

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Please verify that you are human*
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MOBILEYES OPTOMETRY AND DENTAL

1) Patient's Details

If YES, you may skip to 7) Optometry Consent

If YES, you may skip to 8) Dental Consent

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