Tamworth Eye Centre New Paediatric Patient Form

Title

MissMasterOther
Name

First NameLast Name
Middle Name
Preferred Name
Date of Birth

DayMonthYear
Please Choose

MaleFemale
Does the child identify as Aboriginal or Torres Strait Islander?

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

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

YesNo
Next of Kin
Name
Relationship
Phone
Medicare Number
Reference Number (next to your name)
Date of Birth

DayMonthYear
Card Details
Medicare Number
Reference Number (next to your name)
Valid to

MonthYear
Do you have a Pensioner Concession Card?

YesNo
Card Number (CRN)
Card Expiry Date

DayMonthYear
Date
Do you have a Health Care Card?

YesNo
Card Number (CRN)
Card Expiry Date

DayMonthYear
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.
Name of Child
Name of Parent/Guardian
Signature of Parent/Guardian
Medical History
Allergies?

YesNo
Please list
Please tick if the child has any of the following conditions and list relative medications:

AnxietyDepressionArthritisAsthmaEmphysemaCancerDementia/Alzheimer'sParkinson's diseaseMigraineDiabetes Type 1Diabetes Type 2Thyroid diseaseHeart conditionHigh blood pressureHigh cholesterolStroke/Mini stroke/ TIAKidney diseaseLiver diseaseHIVHepatitisMRSA (Golden Staph)Hearing ImpairmentAutism Spectrum DisorderADHDDevelopmental delayGenetic Disorder
Please list current medications
Please list previous operations
Eye Related Medical History
Does the child have a history of eye problems?

Artificial eyeCataractCorneal graftEye infectionForeign bodyGlaucomaKeratoconusLaser treatmentMacular degenerationPterygiumRetinal detachmentSquint
Does the child use eye drops?

YesNo
Please list
Does the child have a family history of the following?

AsthmaAutoimmune disordersCancerDiabetesGlaucomaHeart diseaseHypertensionMacular degenerationStroke
Do any siblings have eyevision problems?

YesNo
Please list
Was the child born prematurely?

YesNo
How many weeks?
Please list the following:
General Practitioner or General Practice
Regular Optometrist/Optometry Practice
Other specialists you attend
Should be Empty:

Address

Contact Phone Numbers

Next of Kin

Card Details

Medical History

Eye Related Medical History

Please list the following: