Submit your information - St John of God Eye Clinic

Patient Identity:

Title

First Name(s)*

Last Name*

Date of Birth*

Home address (Street & Suburb - Not PO Box)*

Postcode*

Billing address same as Home address?

Yes
No

Billing Address

Mobile Phone

Home Phone

Work Phone

Email

Name of Next of Kin

Your relationship to your Next of Kin

Next of Kin - Contact Number

Next of Kin - Address same as own address?

Yes
No

Next of Kin - Address

Medicare Details:

Medicare Number ..... (1)

Medicare Reference Number ..... (2)

Please enter a number from 1 to 9.

Medicare Card Valid To ..... (3)

Private Health Insurance:

Do you have Private Health Insurance?

Yes
No

What is your level of coverage?

Ancillary Only
Hospital Admission & Surgery (+/- Ancillary)

Name of your Health Fund or Insurer

Health Fund Membership Number

Department of Veterans Affairs (DVA):

Are you covered by DVA (Dept of Veterans Affairs)?

No
Yes

DVA File Number

Do you have a Gold Card?

Yes
No

If applicable, please list your:

Pension Number and Type

Health Care Card Number

Who is your Family Doctor & Referrer?

Name of your usual GP

GP's Address

Who is referring you to us?

Please note that Medicare rebates only apply if referral is from a Doctor or Optometrist

Name of your referring Doctor

Address of referring Doctor

Name of your referring Optometrist

Address of referring Optometrist

Name of Person Referring You

Address of Person Referring You

Your Background Information:

Your Current Work Situation

What is your Occupation?

What is your Field of Study (if not school student)?

What was your main previous Occupation?

Have you previously undergone any surgery or laser procedure on your eyes?

Yes
No

Prior Laser corrective eye surgery (Lasik, Lasek, PRK or similar)?

Yes
No

Prior Cataract Surgery or Lens Replacement Surgery?

Yes
No

Cataract / Lens Surgery on Which eye?

Both eyes
Right eye alone
Left eye alone

Date of cataract/lens surgery on Right eye

Date of cataract/lens surgery on Left eye

Please list other surgical eye problems with dates

Please list prior non-surgical eye problems with dates

Previous medical issues

Diabetes - Needing Insulin
Diabetes - Not on Insulin
High Blood Pressure (Hypertension)
Asthma
Emphysema
Other Breathing Difficulties
Heart Problems
Kidney failure
Severe Liver Disease

Details of current & prior medical problems & operations

Please list your current medications and doses

Do you take any blood thinners?

Aspirin or Solprin
Warfarin or Coumadin
Other blood thinner

Name of other blood thinner

Allergies

None known
Sulfa Drugs
Iodine-related dyes or compounds
Fluorescein
I have previously had Anaphylaxis

What gave you Anaphylaxis?

List details of any Allergies

Please list any eye problems within your family

Do you smoke?

Never smoked
Ex-Smoker
Still smoking

Reason for Referral:

Please describe the nature of the eye problems for which you have been referred

Please include dates of onset and duration of the problems