Fill out the form below to send your details online , alternatively a New Patient Registration form is also available for download here.

Fill out the form below to send your details online , alternatively a New Patient Registration form is also available for download here.

Consent

I acknowledge that Retinology Institute will collect and store personal health information about me (and my child(ren) if applicable). This information may be shared with other health professionals for the sole purpose of enhancing your whole health care needs. I give my consent to be part of the Practice’s, National, and State recall and reminder systems.

I agree to the above and understand that I may withdraw my consent at any time.*

Personal Details

Title*
Ethnicity

Communication Preferences

May we use SMS to communicate with you regarding your appointment?*
Do you want us to SMS a carer or relative with your next appointment time?*

(If ‘Yes’ provide their details in the emergency contact section below.)

May we use email to send you correspondence or communicate with you regarding your appointment?*
How did you hear about us?

Emergency Contact

Next of Kin

Is your next of kin different to the Emergency Contact above?*

Billing Details

TAC

Workcover


General Practitioner

Optometrist

Other Medical Specialists

Do you have any other medical specialist involved with your care of this issue?*
Do you have any other medical specialist involved with your care of this issue?*
Do you have any other medical specialist involved with your care of this issue?*

Do you consent to a report and/or medical information on your condition being sent to all medical providers above?*

Medical History

Relevant Files