Who are you registering for?
Some payments are rebatable from Medicare or Veteran Affair DVA.
Would you like to receive patient's report?
The following statements are about the patient's medical history. Tick all that apply.
The following statements are about the patient's ocular medical history. Tick all that apply.
The following questions are about the patient's personal history. Tick all that apply.
Please provide some information about the patient's previous doctors or optometrists.
Add Another Doctor
The following answers are about the patient's family's medical history. Tick all that apply.
Have any of the child's family had any of the following:
The following answers are about the patient's family's medical history. Tick all that apply.
Have any of the child's family had any of the following:
The following answers are about the patient's family's medical history. Tick all that apply.
Have any of the child's family had any of the following:
What activities do they engage with on a regular basis?
What is their current vision status?
Do they have any of the following eye conditions?
How would you describe their cognitive ability?
Do they have any of the following cognitive conditions?
Do they have any of the following health conditions?
Which of the following services would you like us to provide?
When is most convenient for a visit (in the next 2 weeks)?
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