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.
    YesNo

    Personal Details

    Title: DrMrMrsMsOther




    D.O.B:





    Ethnicity: AustralianAborginalTorres Strait IslanderOther

    Communication Preferences

    May we use SMS to communicate with you regarding your appointment?
    YesNo

    Do you want us to SMS a carer or relative with your next appointment time?
    YesNo
    (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?
    YesNo

    How did you hear about us?

    Referring DoctorGoogleFamily/FriendOther

    Emergency Contact



    Next of Kin

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



    Billing Details

    Expiry Date

    Expiry Date

    WhiteGold

    TAC

    Date of accident

    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?
    YesNo

    Medical History


    Relevant Files

    If you have any relevant documents, such as a Doctor's referral, prescriptions or other important information please upload here: