History Form

Contact details

Do you have private health insurance?

Do you hold a pension, health care card, or veterans affairs number?

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?

Covid-19 Vaccination Status

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.

The information we gather from our clients will enable researchers from various disciplines to investigate ocular conditions and develop management strategies for improved patient management. It will also enable us to make important comparisons and evaluations of various pieces of advanced eye imaging equipment, develop evidence-based clinical protocols for a range of eye conditions and ensure that future and current eye-care practitioners have access to up-to-date training.

Before we can use your information for research or teaching purposes, we need your permission.

Confidentiality and Disclosure of Information. Any information that we gather from your appointment at CFEH, that can be identified with you, will remain confidential and will not be disclosed, except as required by law, to yourself or to your consulting practitioner when requested. If you give us your permission by signing this document, we plan to use the information we have collected on you in research activities and to develop teaching materials in the area of eye health.
Note: In any research or teaching material, information will be presented in such a way that you cannot be identified.

Communication of Findings. CFEH will communicate any significant research findings via the Centre’s website, conference presentations and peer reviewed scientific publications.

Voluntary Participation and Withdrawal. Giving CFEH permission to use your information for research and teaching purposes is voluntary. You may decide not to give us permission or withdraw your permission at any time without penalty.

Complaints. Complaints may be directed to the Ethics Coordinator, The University of New South Wales, Sydney 2052 NSW (phone 9385 6222, email humanethics@unsw.edu.au). Any complaint you make will be investigated promptly and you will be informed of the outcome.

Questions. Should you have any questions about research and teaching conducted at CFEH, please feel free to ask us during your consultation. If you have any additional questions later, Michael Yapp, Chief Optometrist (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.

Notification of Additional Research Projects

Occasionally, CFEH also invites clients to participate in additional research projects that are appropriate for their eye condition.

By checking the box below, I give permission to contact me directly to invite me to participate in additional research projects that may be appropriate for my eye condition.


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