Completing this form online before your appointment will allow us to prepare your file prior to your arrival.

Title (required)

Your Name as it appears on your Medicare card (required)

Your Preferred Name

Date of Birth (required)

Address (required)

Home Ph. No

Work Ph. No

Mobile No

Email Address (required)

Medicare No

Occupation

Have you had your eyes examined in the last two years?
YesNo

Health Fund

Does your Health Fund policy include Optical Benefits?
YesNo

What are your hobbies and sports? This will allow us to advise the options available to best meet your visual needs.

Approximately how many hours per day do you use a computer?
hrs

Do you currently wear contact lenses?
YesNo

Do you currently wear prescription sunglasses?
YesNo

The NSW Government’s Visioncare program provides spectacles to financially disadvantaged members of the community and low income earners. Would you like our receptionist to provide you with information about this program?
YesNo