Date of birth
Best contact number
Medicare Reference number
Do you have private health insurance?
Do you hold a pension, health care card, or veterans affairs number?
If so: type of veterans affairs card?
Patient personal information
Prefer not to answer
Country of birth
Are you comfortable speaking English?
What is your first language?
European Descent (Caucasian)
Torres Strait or Pacific Islander
Middle Eastern or Egyptian
Central or South American
Indian or Pakistani
Emergency contact details
Relationship to patient
Emergency contact number
Have you been diagnosed with an eye condition?
Condition(s) diagnosed and year
Have you been referred to an eye specialist in the past?
Name of specialist, reason for visit and year of last visit
Have you had eye surgery?
Type of surgery/surgeries and year of surgery
Are you currently using any prescription or over the counter eye drops?
Name of drops and how often used
Are you currently taking any medications?
Please list all
Do you have or have a history of any of the following medical conditions?
Cancer or tumour
High blood pressure
Liver or kidney disease
None of the above
Does anyone in your family have any of the following conditions?
Unusual eye condition
None of the above
What is the family member(s) relation to you
Do you have any allergies?
Do you have history of any of the following?
Extensive blood loss
Distortion of vision
Poor night vision
Tingling or numbness of the feet
Steroid medication use
Flashes or floaters
None of the above
Are you currently pregnant, breastfeeding or trying to become pregnant?
Covid-19 Vaccination Status
Choose not to disclose at this time
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 email@example.com). 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 (firstname.lastname@example.org 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.
No 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.
Guardian name (if applicable)
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)
Signature (use touchscreen or cursor/mouse to sign)