Patient Registration

Many thanks for making an appointment at Collin & Kirk Optometrists Thornbury.

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

Download PDF Form

Title:

Name (as recorded on your Medicare card):

Preferred Name:

Family Name:

Date of Birth:

Gender Identity/Pronouns:

Address:

Suburb:

Postcode:

Home Phone:

Work Phone:

Mobile:

Email:

Preferred method of contact:

Medicare Number:

Individual Reference Number (IRN) on Medicare Card:

Referred by:

GP Name:

GP Practice Name:

GP Practice Address:

Private Health Insurance Name:

Member No:

Extras?

Your Eyes & Vision

Do you currently wear spectacles?

Would you like new spectacles?

Do you have a spare pair of spectacles?

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?

Do you have sunglasses?

Have you tried contact lenses?

Are you 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.

Have you had any eye treatment or eye operations? If so, when, one eye or both eyes?

Do you rub your eyes excessively?

Do you get itchy eyes?

Do you experience symptoms of dry, scratchy eyes?

Questions I want to ask the Optometrist?

Many thanks for making an appointment at Collin & Kirk Optometrists Thornbury.

Patient Registration

For appointments please contact 9484 1127 or book here and complete our patient registration form.