|
|
|
|
|
|
|
|
Guardian Telephone:
|
|
When was your last eye examination?
Less than 3 years ago More than 3 years ago |
|
Does you child have private health insurance with optical cover?
Yes No
Does your child hold a pension or health care card?
Yes No |
|
Reason for Today’s attendance:
General Check up Referred by Doctor / School Teacher / School Nurse / Maternal Nurse Name: Other reason/referral |
|
GP details
|
|
| How did you come to hear about our practice? |
|
| If Referred by Friend Please Nominate : |
|
Relevant vision and eye health history
Previous history of
Lazy eye Turned eye Spectacle wear Eye surgery
Previous Family history of
Lazy eye Turned eye Spectacle wear Eye surgery
|
|
