New Patient Form New Patient Form "*" indicates required fields Δ Patient DetailsPatient Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Preferred NameDate of Birth* DD slash MM slash YYYY Gender Male Female Different term Do you need an interpreter? Yes No Language spoken other than EnglishOccupationAddress Street Address Suburb State Post Code Phone NumberEmail Address Preferred method of communication Mobile/SMS Email Phone Post/Mail Emergency Contact DetailsContact NameRelationship to PatientContact NumberAlternate Contact (optional)Health Fund DetailsDo you have Medicare? Yes No Medicare NumberRef NoExpiry Date mm/yyyyDo you have a DVA Card? Yes No DVA NumberPlease Select Gold White Do you have Private Health Cover? Yes No Health Fund NameMember NumberRef NoExpiry Date mm/yyyyHospital Cover Yes No Do you have a Pension or Healthcare Card? Yes No Card NumberExpiry Date mm/yyyyDefence PM Keys Yes No Ref NoIs this consultation related to worker's compensation? Yes No Claim NoDate of Accident DD slash MM slash YYYY Lodged? Yes No Healthcare ProvidersOptometrist NamePracticeGP NamePracticeOther health practitionersDr NamePractice Add RemoveHealth history and medicationsHave you been diagnosed with any previous eye conditions? Yes No Please listDo you use any ophthalmic medication/eye drops on a regular basis? Yes No Please listHave you undergone any eye procedure before? Yes No Please listHave you been diagnosed with any general medical conditions? Yes No Please listHave you been diagnosed with diabetes? Yes No Do you take insulin? Yes No Do you take injectable weight loss drugs? Yes No Please listPlease list any psychological/mental health diagnoses you have hadList any medications, supplements or over the counter medications you takeDo you have allergies? Yes No Please listAt Visionare Eye Specialists charges are based on the type of consultation and any diagnostic tests or procedures required. All fees must be paid in full on the day of the appointment. If you have a current referral from your GP or optometrist, consultation fees may be eligible for a Medicare rebate. By signing this form, you acknowledge and agree that all fees are payable on the day of service.Privacy & Consent I agree to the privacy policy.By signing this form, I consent to Visionare Eye Specialists: • Collecting, storing, and maintaining my medical and personal information in accordance with Australian privacy and health record laws. • Using electronic transcription and secure digital systems to document my consultations. • To clinical images to be taken and stored as part of your medical record, and used for education or training in a de-identified form unless you request otherwise • I understand that an observer may be present during my consultation/procedure and that my medical treatment will remain confidential. • Requesting, receiving and sending relevant medical records or reports to or from other health professionals and practices involved in my care. • Retaining and using my health information to provide treatment, manage my ongoing care, and for administrative, billing, and compliance purposes. • Communicating with me by telephone, email, and SMS (including appointment reminders, results follow-up, and practice correspondence). I understand email/SMS may carry some privacy risks. • Contacting me regarding investigation or pathology results but acknowledge that it is my responsibility to contact the practice if I have not received results within a reasonable time. • Charging and requiring payment of fees for services provided, with responsibility for settling any out-of-pocket costs, even if rebates or third-party contributions are available. I understand that: • I may withdraw or update my consent at any time by notifying the practice in writing. • My information will not be shared with third parties except where required or authorised by law, or with my explicit consent. • I am entitled to access my health record, subject to applicable laws and policies.Signature*Date* DD slash MM slash YYYY This is set to today's date by default.
