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Child New Patient Care Form

Welcome to Matthews Vision Care Greerton. Please fill in your childs's details below and click send.

Title
Date of birth
Day
Month
Year
Multi-line address
Ethnicity
Is this a referral or a recommendation?

VISUAL HISTORY

Has there been a previous examination?
YES
NO
Previous treatment
Was pregnancy and birth free from complications?
YES
NO

Were the following development areas as expected:

Walking
Crawling on all fours
Talking
General growth
Ball catching
Tying own shoelaces
Hearing
Language development
Riding two-wheeler

HEALTH

Has the child been hospitalised for any illness?
Has the child experienced any ear infections?
Does the child suffer from any allergies?
Does the child take any medications?
Aer there any diagnosed conditions we should be aware of ?

MSD/WINZ

Do you have a community services card?

If yes, a $287.50 subsidy is available for under 15 year old children

EDUCATIONAL PROGRESSS

Are their difficulties with
Does your child like to read?

SYMPTOMS

Does your child have any of these symptoms. Please check the box that best represents the frequency of occurance of each symptom.

Terms of Account: Full payment is due on collection of goods secured or services rendered unless prior arrangement has been made. Unpaid accounts may include late payment fees and collection costs. Signature confrims these conditions are understood.

Privacy Statement: Information on this form is collected to offer you total petient care. Some data may be provided to other eye care professionals for research and statistical analysis or to third parties/business so you can recieve opportunities that may be of benefit to you.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

If you need a quote for insurance or WINZ please let the receptionist know before your examination.

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