Eyesense Vision Optometrists

ABN 68 686 618 986

Unit 2, 643 Newcastle St

Leederville WA 6007

contact@eyesensevision.com.au

www.eyesensevision.com.au

Welcome To Our Practice 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

Gender

Male Female

Parent/guardian name(s)

Parent/guardian Email

Parent/guardian contact number

Address

Medicare number

Child's reference number

Do you have private health?

YesNo

Name of private health:

How did you hear about us? *

Referred by:

What is the main reason for your visit? *

Medical History

Since many general health conditions can be associated with eye health conditions, it is important for us to have a clear understanding of your medical health and family history.

GP Details and/or other health carers

Has your child been diagnosed with any behavioural or learning difficulties?

YesNo

Please specify:

Has your child had a previous eye exam?

Yes No

When and where was the last eye exam done?

Does your child currently wear glasses?

Yes No

Does your child have other health conditions we should be aware of?

Please list any medications your child is currently taking

Education

Name of school

Year level

Has your child repeated a year?

YesNo

Do you feel your child is reaching their learning potential?

YesNo

Detail your concerns:

Birth and Development

Did you experience any complications during pregnancy?

YesNo

Did you experience any complications during delivery?

Yes No

Specify:

At what age did your child start to crawl?

At what age did your child start to talk?

Is your child right handed or left handed?

RightLeft

Eye Teaming Ability

Focusing Ability

Tracking Ability

Visual Processing Ability

Your 1 hour in-depth eye exam is $249 and already includes a free retinal photography & Computerized eye tracker.

Would you like to add any of the following to your eye exam?

Eye Exam Report ($50)
Receive a detailed report of the test results, diagnosis and recommended treatment plan moving forward.

You'll receive a Medicare rebate of $33.15- $111.15.
You can claim a health fund rebate for your spectacles and/or contact lenses.
Please email any documents from your doctor, teacher 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.

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

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