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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 – Adult

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)

For new patients 15 years and under please see our child form.

Name *

First

Last

Known As/Preferred Name

Date of Birth *

Medicare Number *

Medicare Reference Number *

Medicare Expiry Date *

Sex at Birth

Gender

Home Phone *

Work Phone

email *

Postal address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Occupation

How did you hear about us?

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

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

GP's name and suburb

Do we have your permission to send a clinical report to your GP, if necessary?

Yes
No

Are you under the care of an ophthalmologist (eye surgeon, eye specialist)?

Yes
No

Which ophthalmologist (eye doctor) and where?

Which condition(s) are you seeing the specialist for?

Do we have permission to send a clinical report to your ophthalmologist if necessary?

Yes
No

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

Yes
No

What is the MAIN reason for booking the appointment?

Do you have any other concerns about your eyes?

Roughly how long has it been since your last eye check?

Do you currently wear glasses?

Yes
No

If yes, please bring them to your appointment.

Do you have any frustrations or concerns with your current glasses?

Does your licence require you to wear glasses to drive?

Yes
No

Do you wear contact lenses?

Yes
No

Do you ever experience any of the following (check all that apply)?

Headaches
Eye Fatigue
Red/sore/watery eyes

Do you require safety glasses for your occupation or sporting activities?

Yes
No

What percentage of your work day do you spend using a smartphone/tablet/device/computer?

What percentage of your personal time do you spend using a smartphone/tablet/device/computer?

Please list any health conditions and current medications

Please list any allergies

Have you ever had a reaction to any eye drops or eye medications?

Yes
No

Are you diabetic?

Yes
No

Do you have a family history of diabetes?

Yes
No

If yes, who in the family has diabetes?

Do you have a family history of any of these eye conditions? (check all that apply)

Glaucoma
Macula Degeneration
Keratoconus
Other

Who in your family has been diagnosed with this eye condition?

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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