Patient Registration

* indicates mandatory fields

Personal Details

Title...*MrMrsMissMs


Gender...*FemaleMale

Are you covered by Private Health Insurance*?
Select...YesNo

Do you have a current Concession Card?*
Select...YesNo

Lifestyle Details

Do you currently wear glasses?*
Select...YesNo

Do you currently wear contact lenses?*
Select...YesNo

Do you spend a lot of time outdoors?*
Select...YesNo

Do you have a problem with glare?*
Select...YesNo

Do you wear prescription sunglasses?*
Select...YesNo

Do you require safety glasses for your occupation or sporting activities?*
Select...YesNo

Does your work require computer use?*
Select...YesNo

Do you have a dedicated pair of computer/office spectacles?*
Select...YesNo

How long do you spend per day on computers or other screen based devices?*
Select...Less than 2 hoursMore than 2 hours

Do you experience one or more of the following after extended use?
Eye FatigueHeadachesDry, sore or blurred eyesNeck or shoulder pain

Medical Details

Since many general health conditions can be associated with eye health conditions it is important for us to have a clear understanding of your medical health and family history. Please check any conditions which affect you and/or your family.

How did you hear about us?

Relative / Friend / Previous PatientYour GPInternet Search / Our WebsiteFacebook / Social MediaPrint AdvertOther

Future communication

Are you happy to receive occasional communications including appointment reminders, eye health information and special offers by mail, email and sms?
Select...YesNo