Make An Appointment

If you’re interested in booking a consultation please submit the following form with your details and a member of our team will be in touch shortly to confirm your booking.

New Patient

Returning Patient

First Name

Last Name

Phone

Eye Problem

Preferred Doctor

Preferred Mode Of Contact

Additional Comments (optional)

Title

First Name

Last Name

Date Of Birth

Address

Post Code

Email Address

Mobile Number

Home Number

Would you like a text reminder?

Yes

Ethnicity

Do you have any cultural beliefs or practices that we should be aware of?

Emergency Contact Person

Relationship To You

Contact Number

Usual GP And Practice

Usual Optometrist And Practice

Referral

Optometrist

Web search

Friend

Other

Other, Please Specify

Medications (please List):

Allergies (please List):

Medical Insurance

Policy Number

Are you a Southern Cross member?

Yes

Do you agree to us releasing information to your insurance company or ACC if we receive an official request for information from them?

Yes

Do you agree to us using images / photographs taken as part of your consultation for teaching purposes?

Yes

Please sign if you approve us handling your claim This will be signed in the clinic at your appointment

I confirm that the above details are correct.

I agree and accept that Eyes and Eyelids can provide a copy of my clinical records and details of my consultation(s) to my optometrist, GP, and / or other relevant health professional.

Eyes and Eyelids may use the above details (including my email) to advise on appointments and send correspondence including patient satisfaction surveys.

I understand that I am financially responsible for all charges, whether or not paid for by insurance, for all services rendered on my behalf, and for all debt collection costs associated with my account.

Eyes and Eyelids may have received a referral from your healthcare provider, along with relevant clinical information to assist in your care.

09 222 1828

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