Registration Form

Personal Information

Patient surname(Required)

Patient Given /Name(Required)

As printed in your Medicare Card

Date of birth

Sex

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone

Parent 1(Required)

Prefix First Last

Parent 1 telephone(Required)

Parent 2

Prefix First Last

Parent 2 telephone

Email address(Required)

Email communication confirmation

Yes

No

Please confirm that you are happy to receive communication by email

Patient's Medicare

Parent's Medicare Number

Patient's Medicare Reference number

The number beside your name

Partient's Medicare Expiry Date

MM/YYYY

Parent's Medicare

To enable us to forward the account to Medicare for your rebate we also require the following.

Parent Name

First Last

Name as registered with Medicare.

Patient's Medicare Number

Parent's Medicare Reference number

The number beside your name

Parent's Medicare Expiry Date

MM/YYYY

Parent's Date of birth

Health insurance

Do you have health insurance?

Yes

No

Insurance fund

Member Number

Referring Doctor's/Optometrist Details

Referring Doctor's/Optometrist Name

Referring Doctor's/Optometrist Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referring Doctor's/Optometrist Telephone

Local GP and Clinic Details

Same as Referring Doctor

Different to above

Local GP Name and Clinic

Local GP and Clinic Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Local GP and Clinic Telephone

Patient Medical history

Does your child have a Royal Children's hospital history?

No

Yes

Their UR Number is:

Birth Weight

Order of Birth

Was this birth premature?

Yes

No

By how many weeks?

At which hospital was he/she born?

Was the delivery?

Normal

Forceps

Caesarean

Was your child well after their birth?

Yes

No

Please provide any details if unwell.

Family Medical History

Is there any eye disease that runs in the family?

Yes

No

Please provide details of the eye disease(s).

Privacy, photography and consent

Privacy Statement

The information provided on this form is collected for the purpose of providing comprehensive Healthcare, this information will be retained on the patient record and kept confidential. The Patients record may however be disclosed to a third party involved in the care and under certain circumstances – where required by law or when requested by another medical practitioner/hospital including emergency medical care

Clinical Photography

Photographs or videos may be taken to record clinical findings. These may be used for:

Documenting your medical history
The teaching of health professionals and students studying healthcare here and in other hospitals/colleges/universities
The education of patients with conditions similar to yours. If publication in medical and scientific journals or textbooks is considered you will be contacted to obtain specific written permission.

Financial Consent

I understand that I will incur out of pocket expenses and that the fees are due and payable on the day of consultation.

Note: minimum 24hrs notice required for cancellation or non attendance, otherwise a cancellation fee applies.

Please tick the box below to confirm you have read and understood the privacy statement/photograph and financial consent

Patient consent(Required)

I understand and agree to the privacy statement, agree to Clinical Photography and provide my financial consent.

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Online Registration Form

Personal Information

Patient's Medicare

Parent's Medicare

Health insurance

Referring Doctor's/Optometrist Details

Local GP and Clinic Details

Patient Medical history

Family Medical History

Privacy, photography and consent

Privacy Statement

Clinical Photography

Financial Consent