General Information

First Name

Surname

Date of birth

Age

Gender

MaleFemaleOther

Email

Phone

Address

How did you hear about EyeSense Vision and Therapy Centre? *

Occupation

Referred by:

Additional Information

1. Any eye or vision concerns

2. Medicare No

Reference No

3. GP Details and/or other health carers

4. Current Medications

5. Brief Health History

6. Family History of General and/or Eye Disease or Treatment

7. Any history of concussions, serious injuries, or migraines

Costs will be approx. $140 -$190 for a 1 hour extensive appointment with a part Medicare rebate.
Health fund rebates can be submitted privately with your receipt.
Health fund rebates for spectacles and contact lenses can be claimed at the same time as you make payment in the office.
Our premises are located in the front office building on the ground floor to the right of the front door.
Parking is next door in the carpark to the left of the building with a gate code 3588# for entry.

Our allocated spaces are the 3rd and 4th on the right after entry.

Please DO NOT PARK in another space or you will be fined by City of Vincent.

Our allocated spaces are the 3rd and 4th on the right after entry.

Please DO NOT PARK in another space or you will be fined by City of Vincent.

If you have any documents you would like your optometrist to read, such as a doctor or teacher report, please email the documents to contact@eyesensevision.com.au.

If you have any of the following symptoms, please contact us to reschedule rhe appointment:

Sore throat or coughFeverTrouble breathingRunny nose

Thank you for choosing EyeSense Vision and Therapy Centre for your personal vision and eye health care. Please contact us if you have any questions, we look forward to meeting you!

Simoné Fanoy B Optom, Grad Cert Oc Ther, Ocular Medicines Prescriber

Liz Wason Dip App Sc (Optom), Grad Cert Oc Ther, FACBO, Ocular Medicines Prescriber

Steve Leslie B Optom FACBO FCOVD Grad Cert Oc Ther, Ocular Medicines Prescriber