Patient Registration

Personal Details

First Name *

Surname *

Date of Birth *

Gender

Parent/Guardian Name (if patient is under 18)

Email *

Phone Number *

Street Address

Suburb

State/Territory

Reason for Visit

Current Symptoms

Eye Care History

How long ago was your last eye exam? *

Do you currently wear glasses or contact lenses? *

Select all that apply

Glasses Contact lenses OrthoK Night Lenses None

Are you happy with your current glasses?

Yes No Somewhat

Tell us why?

What type of contact lenses do you currently wear?

Soft Lenses Hard Lenses (RGP) OrthoK Night Lenses Scleral Lenses Hybrid Lenses Other

Soft lens modality:

Are you happy with your current lenses?

Yes No

Please describe any issues or concerns

Are you interested in trying contact lenses again or knowing more about the latest generation of lenses?

Yes No Maybe

Are you interested in trying contact lenses or knowing more about them?

Yes No Maybe

Eye Health History

Please specify other eye condition

Have you had any eye surgeries in the past?

Yes No

Please provide details about your eye surgeries

Family Eye History

General Health

Are you currently taking any medications?

Yes No

What medications are you currently taking?

Do you have any allergies?

Yes No

What allergies do you have?

Please specify

Name of your General Practitioner

So we can report back to them if necessary

Medicare & Insurance

Do you have Medicare? *

Yes No

Do you have private health insurance? *

Yes No

Health insurance provider

Does your health insurance have optical cover?

Yes No Unsure

Do you have a referral? (not necessary)

Yes No

Name of referrer or practice

Please bring referral letter with you to your appointment.

Myopia Management

Based on your previous responses in regards to myopia (short-sightedness) risk, we'd like to ask a few more questions to help guide your care.

Has your prescription changed recently?

Yes No Unsure

Are you interested in learning more about treatments to slow myopia progression?

Yes No

Any previous myopia control treatments?

What to expect at your appointment

Axial length measurement

Axial length measures your eye's physical growth and is the gold standard for tracking myopia progression. It accurately shows whether treatment is working across all options, including OrthoK, where prescription alone can't reveal true eye growth. Tracking it lets us detect changes early - even before myopia develops - so we can start preventative care sooner.

Myopia management discussion

If indicated, your optometrist will discuss myopia management options with you during your consultation. Our clinic offers a full range of myopia management interventions to slow the progression of myopia, including OrthoK, myopia control contact lenses, treatment glasses, atropine eye drops, and red light therapy.

Corneal topography

If OrthoK or contact lenses are of interest after discussing your myopia management options, a corneal topography scan may also be performed.

If you're concerned about myopia progression, please bring:

Current and previous glasses or contact lenses, to help us gauge prescription changes over time
Previous eye test results, if available (including axial length measurements, if you've had these done before)
A referral letter, if you've been referred by another optometrist or practitioner (not necessary if you haven't)

Dry Eye Management

A few additional questions will help us better understand your eye discomfort, so we can guide your care and help alleviate your symptoms.

Can you tell us more about your dry eye symptoms?

Select all that apply

Burning or stinging Gritty or sandy sensation Watery eyes Fluctuating or blurry vision Sensitivity to light Eyes feel tired, especially by end of day Discomfort wearing contact lenses Worse with screen use, air conditioning, or heating Other

Please describe

Have you had any previous dry eye treatments?

Yes No

Our clinic offers a full suite of treatments to manage dry eye conditions from mild to severe cases, including:

✓Intense Pulsed Light (IPL)
✓Low Level Light Therapy (LLLT)
✓Blephasteam Eye Spa
✓Zest lid cleaning procedure
✓Meibomian gland expression
✓Medical treatments
✓Scleral lenses

Your optometrist will discuss your suitability for these treatments following your consultation and dry eye assessment.

Orthokeratology (OrthoK / OK Lens)

As you specified OrthoK Assessment as a reason for your visit, tell us the reason/s for your interest in OrthoK night lens treatment

Select all that apply

Myopia control to slow myopia progression Vision correction to be glasses-free Dry eye symptoms with regular contact lenses Not suitable for, or worried about, laser eye surgery Other

Has your prescription been stable recently or has been changing?

Stable Changing Unsure

As part of your assessment to determine your suitability for OrthoK, your optometrist will be performing a series of scans to measure your cornea shape using an instrument called a corneal topographer.

To ensure that the best quality scans are captured, it is advisable that you do not wear contact lenses on the day of your appointment, if possible. Should you have any questions, please contact our team before your visit.

OrthoK Details

Some additional questions as you are or have been an OrthoK lens wearer

How long have you worn OrthoK for?

<1 yr 1-2 years 2-3 years >3 years

Are you happy with your current OrthoK lenses?

Yes No - more details

Were you fitted with OrthoK lenses in Australia or overseas?

Australia Overseas

Please remember to bring:

Your current OrthoK lenses, solutions and any accessories so we can understand what you've been wearing and using previously for your OrthoK treatment. This helps us provide the best care for you.

Advanced Eye Health Care

As your responses have indicated elevated eye health risks, additional advanced tests or scans may be needed to thoroughly assess the health of your eyes. Your optometrist will discuss these tests with you during your consultation.

OCT (Optical Coherence Tomography) 3D Retinal Scans

OCT is a laser-based imaging technology that provides high-resolution cross-sectional images of your retina and optic nerve. It allows us to assess the health of retinal structures and layers that cannot be seen during a standard eye examination.

Optos Ultra-Widefield Retinal Imaging

Optos captures an ultra-widefield image of your retina (up to 200 degrees), giving us a comprehensive view of your peripheral retina. This is particularly helpful for detecting peripheral retinal changes and abnormalities not visible with standard imaging. These scans can be done without dilating eye drops so you can safely drive afterwards.

OPTOS - 200° ULTRA-WIDEFIELD SCAN COVERAGE

3D-OCT - CROSS-SECTIONAL LAYER ANALYSIS

A few final questions

How did you hear about us? *

Is there anything else we should know before your appointment?

Consent & Privacy

I confirm the information provided is accurate. * I consent to the collection of my personal information for clinical care. *

Let’s save you some typing

Patient Registration

Personal Details

Reason for Visit

Current Symptoms

Eye Care History

Eye Health History

Family Eye History

General Health

Medicare & Insurance

Myopia Management

What to expect at your appointment

Axial length measurement

Myopia management discussion

Corneal topography

If you're concerned about myopia progression, please bring:

Dry Eye Management

Our clinic offers a full suite of treatments to manage dry eye conditions from mild to severe cases, including:

Orthokeratology (OrthoK / OK Lens)

OrthoK Details

Please remember to bring:

Advanced Eye Health Care

OCT (Optical Coherence Tomography) 3D Retinal Scans

Optos Ultra-Widefield Retinal Imaging

A few final questions

Consent & Privacy

Thank You!