(For Medicare claiming purposes)
If yes is he/she moderately or extremely active? TELEVISION VIEWING/LEISURE TIME ACTIVITIES
IT IS OFTEN BENEFICIAL TO EXCHANGE INFORMATION AND DISCUSS YOUR CHILD'S RESULTS WITH HIS/HER SCHOOL AND OTHER PROFESSIONALS INVOLVED IN HIS/HER CARE. PLEASE SIGN BELOW TO AUTHORISE THIS EXCHANGE OF INFORMATION.
I give my consent to make copies of my child's record and share any pertinent data from this exam to the school and other professionals. I also give my consent to provide any information to the health care providers
This authorisation shall be considered valid throughout the duration of treatment.
From time to time it may be necessary and useful to photograph your child in order to obtain records of eye movements, body movements and the like. The records are for the express use of the optometrist and therapist to gauge and monitor change and progress. They will not be provided to any external sources without your prior consent.
I give my consent for my child to be photographed if clinically necessary.
At times it may be necessary at times to guide you child with prompts which may require either the optometrist or therapist to gently touch your child. This will mostly be on the head, arm or leg and occasionally trunk or hips. This will usually be during therapy or during the assessments. We will always check with you first and you will always be present at these times.
I give my consent for the optometrist or therapist to make body contact with my child if clinically necessary.
Thank you for carefully completing this questionnaire. The information you supplied will allow us to provide a more comprehensive evaluation and better meet your child’s specific visual needs.
If you have any questions, please contact our office at 02 9982 1039 priorto your appointment. We request a minimum of 24 hours’ notice if you are unable to keep this appointment.