New patient registration

At Retinology Institute we manage macular, retinal and vitreous diseases. Our friendly practice is located in Glen Iris, Melbourne; where we have state-of-the- art equipment to facilitate accurate diagnosis’ and optimal treatment.

New Patient Registration Form

If you are new patient wishing to organise an appointment, please fill in the form below. One of our friendly team members will be in contact with you shortly.

Alternatively, you can phone our rooms on (03) 8823 9000 or 1300RETINA; or send us an email at:

  • Personal details
  • MM slash DD slash YYYY
    • Contact details
    • Next of kin
    • Medical information
        • General practitioner details
        • Optometrist
        • Do you consent to a report from your appointment being sent to your GP and/or Optometrist?
      • Medical history
        • We endeavour to provide you with optimal medical care. This requires us to collect your personal and health information. At times this information may be required to be shared across an extended medical team. Your information will also be used for administrative and billing purposes and may be shared with other agencies, such as Medicare and private health funds, as required. Your health information may be used for such secondary purposes as research, trials and audits. No information that personally identifies you will be disclosed for these purposes.

        • I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I have advised:
        • Hidden