Paediatric New Patient

Your paediatric appointment includes an in-depth consultation with Dr Moorthy and her team, as well as a series of initial diagnostic assessments.

Medicare rebates are applicable with a valid referral from your GP or optometrist. This will be advised at the time of billing. Paediatric clinics run monthly.

Please also note the following:

PLEASE ALLOCATE TWO HOURS FOR YOUR APPOINTMENT
Your child’s pupils may be dilated on the day, which is safe and will last for up to 24 hours.

For great videos showing you what to expect at the appointment and information on paediatric eye conditions, please visit the American Association for Pediatric Ophthalmology & Strabismus. We have found this to be a helpful resource for patients.

Please complete the online form below. If you have any issues completing the form, you may complete the form on the day of your first appointment.

Paediatric Patient Registration & Release of Information Consent

Patient Details

Name

Date of Birth

Address

Home Phone

Mobile No.

Emergency Contact Name

Medicare No.(Required)

Medicare Ref.(Required)

Medicare Expiry(Required)

Health Fund Name

Health Fund Membership No.

Health Fund Ref.

Health Fund Expiry

Parent Full Name

Parent Date of Birth

Parent Medicare No.

Parent Medicare Ref.

Parent Medicare Expiry

GP / Optom. Details

Referring GP / Optom.

Your GP / OPTOM (if different to above)

Medical History

Birth History: Length of Pregnancy

Are there any current developmental issues?

Allergies

I consent to the use of my personal health information by EyeHub and disclosure of my personal health information to other health professionals to assist with my continuing care.

I consent to EyeHub using my personal information to submit claims to Medicare on my behalf.

Phone

This field is for validation purposes and should be left unchanged.

Paediatric Patient Registration & Release of Information Consent

Patient Details

GP / Optom. Details

Medical History

Do not let poor eye health define you.