Prescription Glasses & Eye Exams | Book Today

Book an appointment

Please complete the following form below to allow us to give you the highest quality of care. All information provided is kept secure and confidential.

Alternatively, you can download a PDF version of this form and email the form back to thornbury@collinandkirk.com.au

Patient details:

Title

Name

Preferred Name

Family Name

Date of birth

Pronouns

Address

Home Phone

Work Phone

Mobile

Preferred Method of Contact

Your eyes & vision

Do you currently wear spectacles?

Would you like new spectacles?

Do you have a spare pair of spectacles?

Do you have sunglasses?

Have you tried contact lenses?

Are your currently being treated for:

Diabetes

High Cholesterol

High Blood Pressure

Do you currently take medication prescribed by a doctor?

If so, please record here or bring a list of your medication to your appointment.

Do you rub your eyes excessively?

Do you get itchy eyes?

Do you experience symptoms of dry, scratchy eyes?

Do you have any questions you’d like to ask the Optometrist?

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Medicare details:

Medicare Numbers

Individual Reference Number (IRN)

GP details:

GP Name

GP Practice

GP Practive Address

Individual Reference Number (IRN)

Private Health Insurance Name

Member Number

Number of hours on the computer, phone or iPad every day?

Are there occasions when you would like to be spectacle free?

How old are your spectacles?

Please prove you are human by selecting the Car.