History Form

Contact details

Patient personal information

Gender

Are you comfortable speaking English?

Ethnic origin/background

Emergency contact details

Have you been diagnosed with an eye condition?

Have you been referred to an eye specialist in the past?

Have you had eye surgery?

Are you currently using any prescription or over the counter eye drops?

Are you currently taking any medications?

Do you have or have a history of any of the following medical conditions?

Does anyone in your family have any of the following conditions?

Do you have any allergies?

Do you have history of any of the following?

Confidentiality and disclosure information

Centre for Eye Health (CFEH or the Centre) is committed to safeguarding the privacy of our patients. The Centres Privacy Policy can be found here.

Any information that we gather from your forms or appointment that can be associated with you, will remain confidential and will not be disclosed except to your referring practitioner or as per below.

For some appointment types sending a copy of the results and images obtained from your assessment at the Centre to your General Practitioner (GP/Family Doctor) is in the best interests of your health care.

If you permit CFEH to send a copy to your GP if appropriate, please provide their details below.

Research and teaching

In addition to providing access to advanced eye imaging and assessment services, Centre for Eye Health is a valuable resource for research and teaching.

If you consent, any information will be presented in such a way that you cannot be identified.

Participation is voluntary. You may decide not to give us permission or withdraw your permission at any time.

Questions

Please feel free to ask us during your consultation. If you have any additional questions later, Michael Yapp, Head of Clinical Operations and Teaching (enquiries@cfeh.com.au or 02 8115 0700), will be happy to answer them.

Patient Permission Statement

By checking the box below, I consent to the use of any de-identified data acquired during my assessment for research and teaching purposes.

Agreement

By signing this Patient Registration Form, I agree to abide by CFEH Patient Terms and Conditions. I also acknowledge that the information I have provided above is, to the best of my knowledge, accurate and complete and that I may be contacted by the Centre as needed.

Patient signature (or parent/legal guardian)

 
Clear Signature Pad