Home
About Us
Auckland Eye Blog
Careers
Contact Us
Cost and Financing
Eye Conditions
FAQ
FAQ – Gutenberg
General Practitioners
Auckland Eye Manual for General Practitioners
Brochures & Downloads
Latest News
Referral Form
Research
Resources & Forms
Thank you for submitting the Auckland Eye online referral form
Webinars & Events
Interactive Eye Model
Interactive Eye Model
Laser Eye Surgery
Laser suitability quiz
Laser Vision Correction
Online Eye Tests
Amsler Grid Eye Test
Optometrists
Auckland Eye Manual for Optometrists
Brochures & Downloads
Latest News
Referral Form For Optometrists
Resources & Forms
Thank you for submitting the Auckland Eye online referral form
Webinars & Events
Patient Forms
Philanthropy & Volunteer Work
Privacy Policy
Referral Form
Research & Clinical Trials
Contact us
For Participants
For Sponsors/CROs
Register for a Trial
Specialists
Technical issues with our main phone line
Terms of Service
Thank you
Thank you for completing the patient registration form
Thank you for completing your pre-op health questionnaire.
Thank you for referring your patient to Auckland Eye
Thank you for registering for our event
Thank you for requesting a callback to book your free laser assessment at Auckland Eye.
Thank you for requesting an appointment
Thank you for your submission
Typography
主頁
Patients
Optometrists
General Practitioners
中文
EN
Search
Laser Eye Surgery
Life-changing Laser Eye Surgery
Laser Eye Surgery
SMILE Pro
LASIK
PRK
PRESBYOND
Laser Eye Surgery
Cost and Financing
Laser suitability quiz
Vision Correction
Life-changing Vision Correction
Vision Correction
Cataract Surgery
Implantable Contact Lenses (ICL)
Refractive Lens Exchange (RLEX)
Eye Conditions
Eye Conditions
We treat more conditions than any other clinic
View All
Aesthetics
Amblyopia
Blepharitis
Oculoplastic
Cataract
Diabetic Retinopathy
Dry Eye Clinic
Dry Eye Syndrome
Epiretinal Membrane (ERM) and Vitrectomy
Floaters & Flashes
Genetics
Children’s Eye Problems / Paediatric
Glaucoma
Implantable Contact Lenses
Keratoconus
Watery Eye / Epiphora
Macular Degeneration
Macular Holes
Orthoptists
Pterygium / Pingueclum
Retinal Tears & Detachments
Refractive Lens Exchange
Squints (Strabismus)
Surgical Retina
Trichiasis
Uveitis & Iritis
Specialists
We have 19 world renowned ophthalmologists
All Specialists
Dr Stephen Best
Dr Chi-Ying Chou
Dr Justin Mora
Dr Sue Ormonde
Dr Sarah Welch
Dr Riyaz Bhikoo
Dr Dean Corbett
Dr Yvonne Ng
Dr Taras Papchenko
Dr Aaron Wong
Dr Stuart Carroll
Dr Sarah Hull
Dr Rachael Niederer
Dr David Pendergrast
Dr Joel Yap
Dr Shenton Chew
Dr Archie McGeorge
Dr Sid Ogra
Dr Alison Pereira
Research
For Participants
For Sponsors/CROs
Register for a Trial
About Us
About Auckland Eye
Philanthropy & Volunteer Work
Contact
Auckland Eye Blog
FAQs
Careers
Patient Forms
Research
We help the world see better
Research
For Participants
For Sponsors/CROs
Register for a Trial
About Us
NZs Leading Private Eye Clinic
Clinic details
About Us
About Auckland Eye
Blog
Careers
Philanthropy & Volunteer Work
Contact
FAQs
Overview
How To
Eye Care
The Eye
Patient Forms
Request an Appointment
Patient Registration
Patient Health Questionnaire
Adult Pre-op Health Questionnaire
Paediatric Pre-op Health Questionnaire
Find Us
Home
Book Now
中文
Book Now
Optometrists
General Practitioners
Book Now
Patient Health Questionnaire
"
*
" indicates required fields
NHI number
Full Name
*
Email
*
Phone
Eye History
Please tick any conditions you currently have or have had in the past
Dry eyes
*
Yes
No
Please provide details:
*
Eye injury
*
Yes
No
Please provide details:
*
Previous eye surgery
*
Yes
No
Please provide details:
*
Previous eye laser treatment
*
Yes
No
Please provide details:
*
Wear Glasses
*
Yes
No
When was the last time you had the prescription checked?
*
Wear Contact Lenses
*
Yes
No
When was the last time you had the prescription checked?
*
Family Eye History
Does anyone in your family have any of the following conditions?
Glaucoma
*
Yes
No
Please provide details:
*
Macular Degeneration
*
Yes
No
Please provide details:
*
Retinal Detachment
*
Yes
No
Please provide details:
*
Other
*
Yes
No
Please provide details:
*
Medical History
Do you have any of the following conditions?
Asthma / Respiratory Disease
*
Yes
No
Please provide details:
*
Diabetes
*
Yes
No
Please provide details:
*
Heart Condition
*
Yes
No
Please provide details:
*
High Blood Pressure
*
Yes
No
Please provide details:
*
Thyroid Disease
*
Yes
No
Please provide details:
*
Pregnancy / Breastfeeding
*
Yes
No
Please provide details:
*
Allergies
Do you have any allergies?
Medicines
*
Yes
No
Please specify / Reaction
*
Food
*
Yes
No
Please specify / Reaction
*
Other
*
Yes
No
Please specify / Reaction
*
Current Medications
List all medications including eye drops and non-prescription
List
Name
Dose
Frequency
Add
Remove
Additional Information
Do you drive?
Car
Truck
Taxi
Bus
N/A
Do you smoke?
Never Smoked
Ex-Smoker
Smoker
Cigarettes / Day
*
What is your occupation?
Is there any other relevant or helpful information you wish to tell us?
Name
This field is for validation purposes and should be left unchanged.
Δ
Call Us
Book an Appointment
Book a FREE Laser Assessment
Find Us
Request a Callback
or
Select your preferred location
Book Online at Remuera
Book Online at Takapuna
Book Online at Ormiston
Book online at Queenstown
