Welcome to the Practice

New Patient “Welcome to the Practice” form

To best help us take care of your needs, we request that all new patients please complete the “Welcome To The Practice” form below and click the ‘Submit’ button. Alternatively you can print a copy of this form >> Click Here, complete it and either email it to reception@racecourseroad.com.au or print it out and bring it with you to your appointment.

Thank you.

“Welcome To The Practice” form download

Name (required)

D.O.B.

Address (required)

Phone (home)

Phone (work)

Mobile

Email (required)

Occupation

GP

Are you in a private health and have “extras” cover? (Name of cover if Yes):

When was your last eye test?

By Whom?

Do you currently wear spectacles?
 Yes No

If "Yes" are they:
 Distance Only Reading Only Multifocals/Progressive Bifocal/Trifocal

If "No" have you ever worn spectacles?
 Yes No

Do you currently wear Contact Lenses?
 Yes No

If "Yes" are they:
 Soft Disposable Hard/RGP Continuous Wear

What sports do you play?

Any hobbies?

How did you hear about us?

Digital Retina Photography
A “Digital Retinal Image” is taken for ALL of our patients. The fee for these Photos is $15.00 and DOES NOT attract a Medicare Rebate but may be claimed from Private Health Insurance if allowable. This photograph provides a baseline record for monitoring any future changes or conditions and can be provided to your GP or specialist by request.

Medicare and Bulk Billing Changes
Due to Medicare changes from 01/01/15 the following condition applies:
Bulk Billing is done for all patients except when a new patient has been to another Optometrist within the previous 3 years. In this situation the full consultation will be charged and the patient then claims the rebate from Medicare. Subsequent consultations will be Bulk Billed as normal.

 I have read this condition and agree to this condition

OCT Scanning – Advanced Eye Health Testing
This scan is performed if required and is definitive in the diagnosis and monitoring of macular degeneration. It does not attract a Medicare Rebate and is paid privately. Some (but not all) Private Health Funds do provide cover for this scan. Your optometrist will discuss this with you if this scan is important for monitoring your eye health.

Pupil Dilation
As part of your Comprehensive Eye Examination we sometimes dilate the pupils of your eyes to thoroughly examine the retina. Some people cannot drive for a few hours after the dilation. If dilation is required do you prefer us to :

 Dilate my eyes today if necessary Reschedule another appointment if dilation needs to be done

Contact via email, SMS or mail
 email SMS mail
 Yes to all the above Yes, but only:-

BOOK AN APPOINTMENT

Need an eye test?

Looking for frames or sunglasses?

Ring now to book an eye test or consultation

Ascot Optical

3/137 Racecourse Road, Ascot, Qld 4007
(next to Coffee Club, parking underneath)

Phone: 07-32681822

Email:  reception@racecourseroad.com.au