Eyesense Vision

ABN 66 767 795 649

Unit 2, 643 Newcastle St

Leederville WA 6007

contact@eyesensevision.com.au

www.eyesensevision.com.au

Neuro-Optometry Welcome Form

Please complete this fillable form BEFORE your appointment and

return it by clicking the SUBMIT button at the end. Please bring your hospital discharge form if you have it when you attend, and any other reports you feel will be helpful to understanding your issues.

Date

General Information

First Name

Surname

Date of birth

Age

Gender

MaleFemaleOther

Email

Phone

Address

Occupation

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

Medicare Number and Reference Number

GP Details and/or other health carers

Current Medications

Details and dates of serious illness or brain injury *

Brief summary of eye and vision concerns.

Additional Information

Date and place of last eye exam:

Do you wear glasses or contact lenses for

Constant wearDistanceReading and computers

Brief Health History

Family History of General and/or Eye Disease

Have you been able to return to work?

YesNo

What activities can you no longer engage in due to your visual difficulties?

Please check the current level of a symptom or problem. All information is confidential.

Due to the complex testing 2 separate appointments of about 1 hour may be needed with total cost of about $240 - $355 (neuro-optometric assessment and imaging of the optic nerve, macula and retina). If computerised visual fields are required there is an extra cost of $ 89; other tests may be necessary, depending on your visual issues. Some tests attract a partial Medicare rebate.
A $100 fee will apply for any cancellation 1 business day before the appointment.
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.

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!

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

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