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New Patient Care Form

Welcome to Matthews Vision Care Greerton. Please fill in your details below and click submit. For children under 16 please fill in the child form.

Title
Date of birth
Day
Month
Year
Multi-line address

VISUAL HISTORY

I give permission to contact previous Optometrist
Are you intending to get new glasses today?

INSURANCE

In this an insurance claim?

MSD/WINZ

Is this examination being paid for by WINZ?
Do you use computers?
Do you drive?
Do you have prescription sunglasses?
Do you have a spare pair of glasses to use in case of breakage of loss?
Do you wear or are you interested in contact lenses?

HEALTH

Are there any diagnosed conditions we should be aware of?
Do you or anyone in your family have glaucoma?
Do you or anyone in your family have macular degeneration?
Do you or anyone in your family have diabetes?
Do you have any allergies?
Do you have any health problems?
Are you taking Medication?
What activities/interests/hobbies do you have ?
What helped you choose to visit our practice ( please tick all that apply)
Date
Day
Month
Year
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 notify the receptionist before your examination.


Terms of account: Full payment is due on collection of goods secured or services rendered unless a written arrangement has been made with Matthews Vision Care Greerton. Unpaid accounts may include late payment dees and collection costs.

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.

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