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Title

Name*

First Last

Date of Birth*

Sex*

Ethnicity*

Contact Information

Address*

Street Address Suburb City Postcode

Phone (Home)

Phone (Mobile)

Email*

Emergency Contact*

Name, Relationship and Phone Number

Optometrist Name & Practice*

GP Name & Practice*

Preferred Pharmacy & Location*

Who referred you to this appointment?*

Insurance Details

Insurance Provider*

Membership Number (if known)

I agree to below terms and conditions*

• You accept that Auckland Eye may access your external health records (e.g. from public hospital and GP) to provide appropriate care for you.

• You confirm that the above details are correct and accept that Auckland Eye will provide a copy of your clinical results and details of your consultation(s) to your General Practitioner / Optometrist / Specialist and / or other referrer. Auckland Eye may use the above details including email to advise of appointments, send correspondence and patient satisfaction surveys.

• Auckland Eye does not have a language interpreting service on site; if required please inform our reception staff who can assist you by providing details of available services.

• You accept that you are responsible for payment of all services received at Auckland Eye and payment is required on the day. We do not guarantee your insurer will fund your consultation fees, tests or procedures so you will be responsible for any costs or co-payments related to these. Please note that fees are subject to change without notification. Failure to attend the appointment or cancel within 24 hours of the appointment may incur a fee.

• Southern Cross Insurance Members: By signing this form you agree that Auckland Eye will manage your claim as an affiliated provider for Southern Cross.

I consent for Auckland Eye to use any images / photographs taken as part of my consultation for teaching purposes*

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