Eyesense Vision Optometrists

ABN 68 686 618 986

Unit 2, 643 Newcastle St

Leederville WA 6007

contact@eyesensevision.com.au

www.eyesensevision.com.au

Neuro-Optometry Welcome Form

Please complete and submit this form before your initial appointment.

This helps us to prepare in advance and provide you with the best possible care.

Date

General Information

First Name

Surname

Date of birth

Age

Gender

MaleFemale

Email

Phone

Address

Occupation

How did you hear about EyeSense Vision Optometrists? *

Medicare Number and Reference Number

Do you have private health?

YesNo

Name of private health:

GP Details and/or other health carers

Current Medications

Description and date of any specific brain injury events *

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 1 hour each may be needed. The cost would be $229 per appointment. This includes a neuro-optometric assessment, imaging of the optic nerve, macula and retina as well as supplementary testing.
If computerised visual fields are required there is an extra cost of $89; it may attract a partial Medicare rebate.
There is a $100 cancellation fee if you cancel yor appointment within 1 business day.
You can claim a health fund rebate for your spectacles and/or contact lenses.
Please email any documents from your doctor or health care provider to contact@eyesensevision.com.au before your appointment.
Parking is next door in the carpark to the left of the building with a gate code 3588# for entry.

Please park in our allocated spaces only. You will be fined for parking in any other space. If these are occupied, there is usually paid parking in Newcastle St.

How would you like to hear about our offers and promotions? *

EmailSMSNo thanks

I consent to the use of Heidi AI for dictation and transcription of my clinical notes, with the understanding that my information will be handled in accordance with privacy and confidentiality requirements. *

Thank you for choosing EyeSense Vision Optometrists for your personal vision and eye health care.

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

Deanna Jordan B.Optom (Hons), Ocular Medicines Prescriber