NSW WOMEN'S WEEK 2026 EVENT: Mobileyes Optometry and Dental Consent Form

NSW WOMEN'S WEEK 2026 EVENT MOBILEYES OPTOMETRY AND DENTAL FOUNDATION
Workshop Consent and Medical History Form
In celebration of NSW Women's Week 2026 Event, Mobileyes Optometry & Dental Foundation is delivering free health and wellbeing events for women and girls, combining inspiring speakers, mental health and resilience education, and free eye and dental care.

All events are FREE and include:
- Speaker sessions on mental health, resilience and leadership
- Free eye care and dental care*
- Tea and light refreshments
- Lunch for participants attending multiple sessions
*If client is eligible for Medicare or Child Benefit Dental Schedule, this will cover some services as per information below.

Please complete this form to register. A single consent form covering event participation, eye care and dental care will be provided below.

Please note:
- Liverpool Girls High School (2 March) and Blacktown Girls High School (4 March) events are for students of those schools only.
- Saturday 7 March – Regent St Pavilion (DOOLEYS) (with Parramatta Mission) is open to women and girls in the community who are in need.
Which Mobileyes IWD service are you registering for?*

Optometry/Dental check and Guest Speaker EventsGuest Speaker Events only
SEE WEBSITE FOR MORE INFORMATION

PROGRAM STRUCTURE
Eye and dental care will be delivered concurrently with speaker sessions throughout the day.

To ensure fair access and smooth scheduling, participants receiving clinical care will be allocated three out of the five speaker sessions, based on their appointment times. This structure will be reflected in the consent form below.
Please provide consent to the following:
I CONSENT to participation in the upcoming eye care and dental care services. This includes the provision of optometry and dental check-ups by qualified professionals.*

YesNo
I CONSENT to participation in the speaker event, which includes attending sessions, listening to presentations, and engaging in any activities related to the event.*

YesNo
I CONSENT to photographs and/or videos being taken at this event.*

YesNo
I understand that images and recordings may be used for reporting, educational, promotional, and awareness purposes by Mobileyes & Dental Foundation and event partners.
(A full consent form is provided below and must be signed.)
SEE WEBSITE FOR MORE INFORMATION

Attendee's Details

Note to parents/guardians: PLEASE ENTER THE CHILD'S OR ADULT'S NAME HERE
Full Name*
Date of Birth*

DayMonthYear
Phone number*
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
Event Date & Locations*
Event Date & Locations*
Have you previously attended a Mobileyes optometry or dental clinic?:*

YESNO / NOT SURE

Parent/Guardian Contact Details
Parent / Guardian Name (If not the patient)
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
SEE WEBSITE FOR MORE INFORMATION

FINAL ACKNOWLEDGEMENT
I understand that: •This is a free event •Places are limited and may be waitlisted •Clinical care and session scheduling will be coordinated on the day
By signing below, you give consent for us to provide the services mentioned above.*

Clear
Please verify that you are human*
SEE WEBSITE FOR MORE INFORMATION
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NSW WOMEN'S WEEK 2026 EVENT MOBILEYES OPTOMETRY AND DENTAL FOUNDATION