New Patient Form New patient Personal DetailsName(Required) First Last TitleMrMrsMsMissMasterDrDate of Birth(Required) DD slash MM slash YYYY OccupationEmail(Required) Phone(Required)Mobile Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Medicare & Health InsuranceMedicare NumberReference NumberPlease enter a number from 1 to 9.Expiry Date 01 Month Year Do you have private health insurance for optical extras? Yes No Health Fund ProviderReason For VisitWhat is the main reason for your visit todayLifestyle DetailsDo you currently wear glasses?(Required) yes no How old is your current pairLess than 1 year1-2 years2 years plusDo you have more than 1 pair? yes no Do you currently wear contact lenses ?(Required) yes no Are your eyes comfortable at the end of the day ? yes no Are you interested in trialing contact lenses yes no Outdoors and ProtectionDo you spend a lot of time outdoors? yes no Do you have a problem with glare yes no Do you wear prescription sunglasses? yes no Do you require safety glasses for work or sport? yes no Computers and screensDoes your work require computer use? yes no Do you have a dedicate pair of computer/office glasses? yes no Daily Screen time? less than 2 hours? more than 2 hours Do you experience symptoms after extended screen usage? yes no What Symptoms? Eye fatigue Headaches Dry,sore or blurred eyes Neck or shoulder pain Hobbies. sports and special interestsMedical DetailsMy local GPAllergies My History Family History Select AllCancer My History Family History Select AllCataracts My History Family History Select AllGlaucoma My History Family History Select AllMacularDegeneration My History Family History Select AllEye Surgery/Injury My History Family History Select AllLazy eye My History Family History Select AllRetinal disease My History Family History Select AllHigh blood pressure or cholesterol My History Family History Select AllStroke My History Family History Select AllHow did you hear about us ?From Friend, family or previous patient My GP Eye Specialist/other optometrist Internet Search/Website Social Media Other If Other please specifyCommunications and ConsentAre you happy to receive appointment reminders, eye health information and special offers by mail, email and SMS?(Required) Yes No .(Required) I have read and understood the RJK Optometry privacy statement Δ
