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Eye Conditions
Blepharitis
Dry Eyes
Retinal Detachment
Ingrowing eyelashes
Drooping eyelids
Floaters
Macular Degeneration
Posterior Capsule Opacification
Cataracts
Procedures
Cataract Surgery
YAG Laser Capsulotomy
Removal Of Eyelid Lumps And Bumps
Chalazion Treatment
Electrolysis for Ingrowing Lashes
My Visit
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Get in touch
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Home
About Us
Eye Conditions
Blepharitis
Dry Eyes
Retinal Detachment
Ingrowing eyelashes
Drooping eyelids
Floaters
Macular Degeneration
Posterior Capsule Opacification
Cataracts
Procedures
Cataract Surgery
YAG Laser Capsulotomy
Removal Of Eyelid Lumps And Bumps
Chalazion Treatment
Electrolysis for Ingrowing Lashes
My Visit
News
Referrers
Get in touch
Search for:
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Contact Info
6 Scott St,Coolangatta QLD 4225
eyecare@mail.com
(07) 55 066 777
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New Patient Registration Form
Home
New Patient Registration Form
New patient registration form
We welcome new patients to our practice to provide the following information prior to their first appointment. This information will be sent directly to our practice.
New Patient Registration Form
New Patient Registration Form
Preferred Doctor
Dr Meon Lamont
Associate Professor Anthony Kwan
Patient Details
Name
*
Title
Given Name(s)
Given Name(s)
Surname
Surname
Date of Birth
*
Preferred phone number
*
Address
*
Address
Street Address
Street Address
Address
Suburb
Suburb
State
State
Post Code
Post Code
Email address
Occupation
GP Details
Doctor Name
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Title
Given Name(s)
Given Name(s)
Surname
Surname
Practice Name
Practice phone number
Address
Address
Street Address
Street Address
Address
Suburb
Suburb
State
State
Post Code
Post Code
Optometrist Details
Optometrist Name
Title
Given Name(s)
Given Name(s)
Surname
Surname
Practice Name
Practice phone number
Address
Address
Street Address
Street Address
Address
Suburb
Suburb
State
State
Post Code
Post Code
Next of Kin
Name
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Title
Given Name(s)
Given Name(s)
Surname
Surname
Phone Number
Relationship to patient
Medicare Details
Medicare Number
The name on your medicare card must be the same name registered with your health fund.
Position on card
The number to the left of your name on your card.
Expiry Date
*
Pension
Pension
*
Yes
No
Pension Number:
*
Expiry Date
*
Health Cover
Do you have private health insurance?
Yes
No
Fund Name
Membership number
*
Do you have a DVA card?
Yes
No
Gold
White
DVA Number
*
Workcover / Insurance / Any other 3rd Party Involvement
Claim number
Case manager name
Phone number
Email
General Health
Have you been diagnosed with any of the following health conditions?
High blood pressure
Asthma
Diabetes
Stroke
Heart conditions
Auto immune conditions (Lupus / Crohns Disease)
Hepatitis (A / B / C)
HIV
None
Other conditions not mentioned above?
Please indicate any allergies
Please indicate any current medications
Please indicate any eye conditions
Please indicate any current eye drops
Please detail any previous eye operations
Please detail any family history of eye problems
How did you hear about the Eye Care Clinic?
Word of mouth
GP
Optometrist
Website
Google / advertisement
If you are human, leave this field blank.
Submit
