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Custom Eyecare Newcastle

Optometrist Newcastle

158 Darby St Newcastle | info@customeyecare.com.au | PH. 4927 0500 Book Appointment

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New Patient Form – Child

After booking an appointment, please submit this form prior to attending your first appointment at Custom Eyecare.

(Note: this form will not book your appointment, please use our online booking link before completing)

This form is for patients aged 15 years and under. For patients aged 16+ please complete our adult form.

Child's Name *

First

Last

Child's Preferred Name (if different to first name)

Child's Date of Birth *

Medicare Number *

Medicare Reference Number *

Medicare Expiry Date *

Sex at Birth

Gender

Parent/Carer's Name *

First

Last

Mobile *

Home Phone

Work Phone

email *

Postal address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

School Name

School Year

Name of Class Teacher

Do we have your permission to send a vision report to the teacher, if necessary?

Yes
No

Do you consent to your optometrist using an AI Scribe to assist in taking notes during your child's consultation? *

Yes
No

Do you have private health cover with extras (ancillary)? If so, which fund?

Child's GP's name and suburb

Do we have your permission to send a clinical report to the GP or other health providers, if necessary?

Yes
No

What are your hobbies/recreational sports (incl swimming)?

Is this your child's first eye examination?

Yes
No

Where and when was their last eye examination?

Does your child currently wear glasses?

Yes
No

If yes, please bring them to the appointment.

What is the MAIN reason for booking the eye examination?

Are there any concerns about the following? (check all that apply)?

Literacy
Tracking
Reading Level
Comprehension
Reading fluency
Concentration

If yes to any of the above, please describe

Have you observed that your child has any of the following habits? (check all that apply)

Eye Rubbing
Forced Blinking
Squinting or Frowning When Concentrating

How much time each day does your child spend on a handheld or close-up screen or device?

How much time each day does your child spend looking at TV screens?

Has your child ever been to an ophthalmologist (eye surgeon/eye specialist)?

Yes
No

Who was the ophthalmologist?

What was the reason and the outcome?

Please list any health conditions and current medications

Please list any allergies

Has your child been under the care of any of the following specialists?

Paediatrician
Speech Pathologist
Occupational Therapist
Psychologist

If yes to any of the above please provide details

Is there any family history of any eye conditions? (check all that apply)

Lazy Eye
Turned Eye
Vision Loss

If yes to the above, what conditions(s) and who in the family has been diagnosed (e.g. brother/parent etc)?

How did you hear about us?

File Upload: If you have a referral letter or other relevant document please upload it here.

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

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Opening Hours

Mon
Tue
Wed
Thu
Fri
Sat
Sun

9.00-5.15
9.00-5.15
9.00-5.15
9.00-7.00
9.00-5.15
By Appointment
Closed

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