Skip to main content

Call: 0247362115

Schedule An Appointment

About Us
- Our Optometry Team
Eye Care Services
- Dry Eye Treatments
Our Glasses
Contact Lenses
- Order Contacts
Medicare and Health Funds
Contact Us

About Us
- Our Optometry Team
Eye Care Services
- Dry Eye Treatments
Our Glasses
Contact Lenses
- Order Contacts
Medicare and Health Funds
Contact Us

Return to top of menu

About Us
- Our Optometry Team
Eye Care Services
- Dry Eye Treatments
Our Glasses
Contact Lenses
- Order Contacts
Medicare and Health Funds
Contact Us

About Us
- Our Optometry Team
Eye Care Services
- Dry Eye Treatments
Our Glasses
Contact Lenses
- Order Contacts
Medicare and Health Funds
Contact Us

Return to top of menu

Home » Hours and Location » Patient Registration Form

Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your optometrist through a secure Internet connection.
Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Mobile Phone
Email Address
Please provide us your email address.
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
How were you referred to our office?
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
Eye History
Please check off any current conditions you suffer from
- I stopped wearing glasses
- I stopped wearing contact lenses
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Blurred Vision at Distance
- Blurred Vision at Near
- Haloes
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
I stopped wearing glasses because:
I stopped wearing contact lenses because:
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:
Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How far do you sit from your monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from
- Chronic fever, unexpected weight loss/gain, fatigue
- Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
- Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
- Respiratory problems (eg. Shortness of breath, wheezing, coughing)
- Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
- Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
- Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
- Skin problems (eg. Rashes, excessive dryness, growths or lumps)
- Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
- Psychiatric problems (eg. Depression, anxiety)
- Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
- Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
- Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature*
Date*
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Δ

Search:

Book An Appointment

Patient History Form

Order Contacts Online

Andrew Mizzi Optometrist

Medical & Fitness Centre, 142 Bringelly Rd
Kingswood, NSW 2747

Phone: 0247362115
Email: info@andrewmizzioptometrist.com.au
(Do not send personal health information by email.)

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 6:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 1:00 PM
Saturday: 9:00 AM - 12:00 PM
Sunday: Closed

Andrew Mizzi Optometrist

Medical & Fitness Centre, 142 Bringelly Rd
Kingswood, NSW 2747

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 6:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 1:00 PM
Saturday: 9:00 AM - 12:00 PM
Sunday: Closed

Schedule An Appointment

Call: 0247362115

Andrew Mizzi Optometrist - Located at Medical & Fitness Centre, 142 Bringelly Rd, Kingswood, NSW 2747. https://andrewmizzioptometrist.com.au

Andrew Mizzi Optometrist - Located at Medical & Fitness Centre, 142 Bringelly Rd, Kingswood, NSW 2747. Phone: 0247362115. https://andrewmizzioptometrist.com.au

Speak Field

© 2025 Powered by

Accessibility
Sitemap
Privacy
Disclaimer
Login