Patient Form New Patient Form YOUR DETAILS Full Name Date Of Birth Home Phone Mobile Email Address Suburb Postcode Occupation Hobbies/Interests Health Insurance No Yes If yes, which one? How did you hear about Grace & Vision Optometrist? From a friend/family From a health provider From school/organisation Search Engine Facebook/Instagram Flyer Do you require a detail written report for a fee of $35? Note: The written report is a comprehensive explanation of the results from the consultation. Results will normally be provided verbally, and your prescription can be provided free of charge. Yes No VISUAL HEALTH QUESTIONNAIRE 1. Do you have Diabetes or other medical conditions? Yes No If yes, please specify: 2. Do you wear glasses? If yes, please bring these to your appointment so we can measure your habitual prescription.. Yes No 3. Are you thinking about a new pair of glasses for your visit? Yes No 4. Are you sensitive to glare? Yes No If yes, would you be interested in transition lenses (change to sunglasses outdoors) to help improve your comfort? Yes No 5. Do you or your children spend more than 30 minutes on screens? Yes No If yes, are you interested in lenses to help reduce tiredness and improve concentration? Especially beneficial for people who work in front of computers daily. Yes No 6. Do you wear Prescription Sunglasses? ie. Protection from cataracts, corneal problems & macular degeneration. Yes No Are you interested in a pair of prescription sunglasses? Yes No 7. Do you wear Contact Lenses? Yes No If no, are you interested in contact lenses? Yes No 8. Do you experience Dry Eyes? Yes No If yes, are you interested in dry eye treatments? Yes No 9. Are you interested in taking Ultra-Wide Field Retina Scan (Cost $55)? Results can indicate signs of retinal tears/detachments, macular issues, and provide a baseline for future reference. This can be done on the same day as your appointment. Yes No 9. Any comments or additional information? SUBMIT Don't Forget To Follow Us Facebook Instagram Back To G&V Website
