Skip to content

Specialists
Conditions
- Cataracts
  - Glaucoma
  - Age-Related Macular Degeneration
- Posterior Vitreous Detachment
  - Diabetic Eye Disease
  - Retinal Detachment
Patients
- Appointments
- Patient Information
Referrers
News
Contact
- Getting Here
07 5616 6008

New patient registration

New patient registration form

We welcome new patients to our practice to provide the following information prior to their first appointment. This information will be sent directly to our practice.

Preferred Doctor

Dr Louise Robinson

Dr Khoi Tran

No preference / next available

Patient Details

Name(Required)

Title Given Name(s) Surname

Date of Birth(Required)

DD slash MM slash YYYY

Preferred phone number(Required)

Address(Required)

Street Address Suburb State Post Code

Email address

Occupation

GP Details

Doctor Name

Title Given Name(s) Surname

Practice Name

Practice phone number

Address

Street Address Suburb State Post Code

Optometrist Details

Optometrist Name

Title Given Name(s) Surname

Practice Name

Practice phone number

Address

Street Address Suburb State Post Code

Next of Kin

Name

Title Given Name(s) Surname

Phone Number

Relationship to patient

Medicare Details

Medicare Number

The name on your medicare card must be the same name registered with your health fund.

Patient Number

Expiry Date

DD slash MM slash YYYY

Health Cover / Pensions

Do you have private health insurance?

Yes

No

Fund Name

Membership number

Tier (gold/silver etc)

Patient number on card

Waiting periods served?

Yes

No

Do you have a DVA card?

Yes

No

Card Number

Expiry Date

DD slash MM slash YYYY

Which colour?

Gold

White

Orange

White card - accepted condition/s

Australian Defence Force Personnel?

Yes

No

PMKeyS/EP ID Number

DAN Number

Workcover / Insurance / Any other 3rd Party Involvement

Claim number

Case manager name

Phone number

Email

General Health

Have you been diagnosed with any of the following health conditions?

High blood pressure

Asthma

Diabetes

Stroke

Heart conditions

Auto immune conditions (Lupus / Crohns Disease)

Hepatitis (A / B / C)

HIV

None

Heart condition details

Auto immune condition

Other conditions not mentioned above?

Please indicate any allergies

Please indicate any current medications

Please indicate any eye conditions

Please indicate any current eye drops

Please detail any previous eye operations

Please detail any family history of eye problems

How did you hear about Coastal Eye Surgeons?

Word of mouth

GP

Optometrist

Website

Google / advertisement

Hope Island Marketplace

Δ

Hope Island Marketplace
Suite 4. Level 1, 99-103 Broadwater Ave Hope Island QLD 4212

CLICK HERE FOR DIRECTIONS

Monday - Friday 8am-5pm
Weekends CLOSED

07 5616 6008

07 5616 6005

© 2021 Coastal Eye Surgeons | Website by Vividus

Privacy Policy | Website Terms

Specialists
- Dr Louise Robinson
- Dr Khoi Tran
Conditions and Treatments
Patients
Referrers
Contact
- Getting Here
07 5616 6008

Specialists
- Dr Louise Robinson
- Dr Khoi Tran
Conditions and Treatments
Patients
Referrers
Contact
- Getting Here
07 5616 6008

Scroll to Top