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798 Nicholson St
Fitzroy North, Victoria 3068
Adult

Adult

Questionnaire for Adults new to our clinic

We ask you to take a few moments to complete this form. The purpose of collecting this information is to assist us in providing you with the highest quality eye-care. All information will be treated in the strictest confidence in accordance with the Privacy Act. As you complete this history questionnaire we hope that you will recognize the thoroughness with which your vision will be considered. The examination will take up enough time to permit a very complete investigation.

    Please sign here to give us permission to contact Medicare if we need to clarify information regarding item numbers:

    Visual History

    Do you experience any of the following?

    Please tick any of these eye conditions that apply to you or run in your family:
    Health History
    Please tick any of these health conditions that apply to you or run in your family:
    • Please detail any other history that you feel may be helpful to us in providing you with Eyecare:

    Optos and OCT scanning will be performed with a fee of $75 ($65 for pension card holders and health care card holders)

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    • Acbo
    • Zacposena
    • Res Rei
    • Prodesign
    • Nora
    • Morel
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    • Masunaga
    • Little Paul And Joe
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    • Garrett Leight
    • Faconnable Kids
    • Face A Face
    • Etnia Barcelona
    • Essilor
    • Dirty Dog
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    • Anne Et Valentin