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Patient Details Form

Patient Details Form

Personal Information

Emergency Contact Information

Financial Information

If yes, please ensure you bring your Medicare card to your appointment.
If yes, please ensure you bring your pension card to your appointment.
If yes, please ensure you bring your DVA card to your appointment.
If yes, please ensure you bring your private health insurance details to your appointment.

Health Information

General Practitioner Information

Optometrist Information

Privacy of Patient Information

Our doctors and staff collect information from patients to provide proper care and treatment. The doctors of Eye Specialist Institute are members of various medical and professional bodies including medical defense organisations. These organisations provide variable services to their members. They require their members to provide information in relation to their medical practice. I acknowledge that my personal information may have to be disclosed to or collected from other doctors, nurses, therapists and medical technicians so that proper health care is not compromised. I give permission to Eye Specialist Institute to store, analyse and publish information collected during my treatment for the purpose of increasing medical and scientific understanding. I understand that if my information is used, my identity will remain confidential. I understand that it may be necessary for information to be transported between Eye Specialist Institute locations and that every care is taken to ensure the safety of this information during transit.

Consent to Dilate

At each visit it may be required to dilate your pupils to allow for a complete examination. Following dilation your vision will be blurry and sensitive to light and you should not drive for at least 2 hours and not until your vision has returned to its normal state. Please sign below that you agree to have your pupils dilated by either the doctor or one of the trained ophthalmic staff.

Southport

1800 111 374

Ground Floor, 2 Short Street, Southport, QLD 4215

Mon
8:00am to 5:00pm
Tue
8:00am to 5:00pm
Wed
8:00am to 5:00pm
Thu
8:00am to 5:00pm
Fri
8:00am to 5:00pm
Sat
Closed
Sun
Closed
Request Appointment

Varsity Lakes

1800 111 374

Level 2, Bermuda Point, 1 Lake Orr Drive, Varsity Lakes QLD 4227

Mon
8:00am to 5:00pm
Tue
8:00am to 5:00pm
Wed
8:00am to 5:00pm
Thu
8:00am to 5:00pm
Fri
8:00am to 5:00pm
Sat
Closed
Sun
Closed
Request Appointment

Coolangatta

1800 111 374

Level 2, The Strand, 72-80 Marine Parade Coolangatta QLD 4225

Mon
8:00am to 5:00pm
Tue
8:00am to 5:00pm
Wed
8:00am to 5:00pm
Thu
8:00am to 5:00pm
Fri
8:00am to 5:00pm
Sat
Closed
Sun
Closed
Request Appointment
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