Patient Registration Form

Date of Birth

First Name

Last Name

Phone: Mobile

Phone: Home

Phone: Work

Home Address:

Suburb:

State:

Postcode:

Postal Address (if different from above):

Suburb:

State:

Postcode:

Email Address

Occupation:

Aboriginal or Torres Strait Islander:

Medicare Number:

Medicare Expiry Date:

Reference Number next to your name: *

Private Health Insurance: *

YesNo

Fund Name:

Name of Insured:

Membership Number:

PENSION CARD NUMBER:

Expiry Date:

VETERANS AFFAIRS (DVA) NUMBER:

Type:

GoldWhite

Expires

WORKCOVER/TAC CLAIM:

YesNo

Name:

Contact Number:

Relationship to you:

Name of Optometrist:

Clinic Name & Address:

Name:

Practice Name & Address:

I am directly responsible for all charges incurred.
I authorise the release of any medical information to insurance companies as may be needed to process my claim.
I authorise the use of fax or email for sending and receiving relevant medical reports/records if required.

Signed: *

Draw signature|Type signatureClear

Date: *