Please complete your Primary Eye Care patient information form.

Patient information form

At which clinic do you wish to create the record?

Title*

First Name*

Last Name*

Date of birth*

Address*

Suburb*

State* Postcode*

Home Phone

Mobile Phone

Medicare number

Medicare patient number on card

Medicare expiry date

Do you wear any of the following? Glasses
Contact Lenses

Do you have a history of eye surgery, eye injury or infection? No
Yes

Do you have any of the following health conditions? Diabetes
Glaucoma
High blood pressure

Do you have any other health conditions?

Do you take any medications?

Do you have any allergies?

Who is your doctor? (Optional for sending reports)

How did you hear about us?

I allow primary eye care to access all relevant information regarding my medical condition.
I understand that primary eye care may be required to forward information about my medical condition or history to other health care providers.
I understand that to provide the highest level of medical care my clinical records may be accessed or reviewed by staff at this practice.

I Agree