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Our Practice
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Our team
Sumba Program
ACO Eye Health
Eyecare
Our Technology
Dry Eye Disease
Intense Pulsed Light (IPL) Information
Children’s Vision
Visiting Canterbury Eyecare: A Guide for Kids
Myopia Management
Common Eye Conditions
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Orthokeratology
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Menu
Our Practice
Why choose us
Our team
Sumba Program
ACO Eye Health
Eyecare
Our Technology
Dry Eye Disease
Intense Pulsed Light (IPL) Information
Children’s Vision
Visiting Canterbury Eyecare: A Guide for Kids
Myopia Management
Common Eye Conditions
Eyewear
Contact Lenses
Order Contact Lenses
Orthokeratology
News
Contact Us
Book an appointment
BOOK AN APPOINTMENT
124 Maling Rd, Canterbury 3126
Mon–Fri: 9.00 am to 5.30 pm Sat: 9.00 am to 1.00 pm
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(03) 9888 6377
ORDER CONTACT LENSES
Our Practice
Why choose us
Our team
Sumba Program
ACO Eye Health
Eyecare
Our Technology
Dry Eye Disease
Intense Pulsed Light (IPL) Information
Children’s Vision
Visiting Canterbury Eyecare: A Guide for Kids
Myopia Management
Common Eye Conditions
Eyewear
Contact Lenses
Order Contact Lenses
Orthokeratology
News
Contact Us
Book an appointment
Menu
Our Practice
Why choose us
Our team
Sumba Program
ACO Eye Health
Eyecare
Our Technology
Dry Eye Disease
Intense Pulsed Light (IPL) Information
Children’s Vision
Visiting Canterbury Eyecare: A Guide for Kids
Myopia Management
Common Eye Conditions
Eyewear
Contact Lenses
Order Contact Lenses
Orthokeratology
News
Contact Us
Book an appointment
BOOK AN APPOINTMENT
ORDER CONTACT LENSES
Welcome to Canterbury Eyecare Form
Welcome to Canterbury Eyecare, we ask that you fill out a few details for us ahead of your appointment.
Title
First name
Last Name
Preferred Name
Email Address
Date of Birth
Phone or Mobile Number
Residential Address
Postal Address (if different to Residential)
Occupation
Do you have private health insurance extras?
Please Select
Yes
No
Medicare Number
Medicare Patient Reference Number
Medicare Expiry
When was your last eye test?
Do you wear glasses?
Please Select
Yes
No
Do you wear contact lenses?
Please Select
Yes
No
No but I would like to try
Please indicate if you have experienced any of the following:
Eye Injury
Lazy Eye
Cataracts
Macular Degeneration
Glaucoma
Eye Infections
Eye Surgery
Heart Disease
Diabetes
High Blood Pressure
Other
If you ticked "Other" please explain below:
Please indicate if anyone in your family has experienced any of the following:
Lazy Eye
Cataracts
Macular Degeneration
Glaucoma
Other
If you ticked "Other" please explain below:
Do you have specific visual needs?
Sports
Hobbies
Computer
Sunglasses
Other
If you ticked "Other" please explain below:
How did you first hear about us? If you were recommended by someone please write their name in "other" section below
Recommended by friend or relative
Live and/or shop locally
Referred by doctor or other professional
Internet
Other
If you ticked "Other" please explain below:
Consultation Fees
Full Initial Consultation:
Scheduled Fee $118.00
Standard Medicare rebate up to $66.15
Retinal photos, 3D OCT Scan and Optomap:
Scheduled Fee $118.00
No Medicare Rebate
Total $218.00
Auxillary Tests
Visual Field Testing:
Scheduled Fee $96.00
Medicare Rebate $63.20
Dry Eye Assessment and Topography:
Scheduled Fee $53.00
No Medicare Rebate
Myopia Master Axial Length Measurement:
Scheduled Fee $43.00
No Medicare Rebate
Corneal Topography:
Scheduled Fee $33.00
No Medicare Rebate
Subsequent and Contact Lens Consultations vary depending on presentation and prescription.
Medicare rebates dependent on date and type of last eye examination.
Privacy Statement
Our practice will deal with your personal information under the guidelines of the Privacy Act. We would like to send you occasional information regarding your eyecare and eyewear. Do we have permission?
Please Select
Yes
No
Thank you and welcome to Canterbury Eyecare, please submit your information below.
Submit responses
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