Welcome to Our Practice. Please complete this form before your child's appointment. Personal DetailsChild's Full Name(Required) First Last Child's Gender Male Female Parent/Guardian's Name(Required) First Last Parent/Guardian's Gender Male Female Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian's Email(Required) Child's Date of Birth(Required) Parent/Guardian's Mobile(Required)Child's Medicare NumberMedicare Ref Number (IRN)Medicare Expiry Date (MM/YYYY)Is your child covered by Private Health Insurance for Optical Extras? Yes No Private Health Fund ProviderWhat is the main reason for your visit today?Lifestyle DetailsIt is important to understand how your child lives their life in order to provide them with a tailored eyewear solution to suit their needs and lifestyle.Does your child currently wear glasses? Yes No How old is their current pair?Does your child currently wear contact lenses? Yes No Are their eyes comfortable at the end of the day? Yes No Are they interested in trialling contact lenses? Yes No Does your child spend a lot of time outdoors? Yes No Does your child have a problem with glare? Yes No How long does your child spend per day on computers or other screen based devices? Less than 2 hours More than 2 hours Does your child experience one or more of the following after extended use: eye fatigue, headaches, dry, sore or blurred eyes, neck or shoulder pain? Yes No Hobbies, Sports and Special InterestsPlease list.Medical DetailsSince many general health conditions can be associated with eye health conditions it is important for us to have a clear understanding of your child's medical health and family history.Your Child's History Allergies Cancer Cataracts Diabetes Eye Injury Eye Surgery Glaucoma Heart Disease High Blood Pressure High Cholesterol Lazy Eye Macular Degeneration Retinal Disease Stroke Tick all that apply.Family History Allergies Cancer Cataracts Diabetes Eye Injury Eye Surgery Glaucoma Heart Disease High Blood Pressure High Cholesterol Lazy Eye Macular Degeneration Retinal Disease Stroke Tick all that apply.Other medical conditions (child or family)How did you hear about us?How did you hear about us? Relative / Friend / Previous Patient Your GP Internet Search / Our Website Facebook / Social Media Print Advert Other If other, please specifyFuture communicationAre you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email and sms? Yes No Privacy Statement & DeclarationOur practice respects your privacy and will comply with the Privacy Act and the Australian Privacy Principles when handling your personal information (including health information). We use your personal information to help us provide services to you. We may also use your personal contact information to send you information regarding eye health, eye care and eyewear, with your consent. By providing the information requested in the first three sections of this form we will be able to make an informed decision on how to best meet your eye care and eyewear needs. We may also need to provide some personal information to third party suppliers (such as providers of mail-out and electronic distribution services and eyewear suppliers) if and to the extent necessary for them to provide the relevant goods or services (for example prescription eyewear or contact lenses). You can access all the personal information that we hold about you. Please contact us if you would like to know more about how we handle personal information or to see or obtain a copy of our full privacy policy.Privacy consent(Required) I have read the Privacy Statement and I am the child's parent/guardian.Parent/Guardian full name (typed signature)(Required)Today's Date(Required) Δ
