By signing this form, I acknowledge that:

• I have been provided with access to the Vision Eye Institute Privacy Policy (available at /privacy-policy/).
• I am aware Vision Eye Institute will store and use my records in the ways described in the policy.
• If I wish to access my medical records, I must make a written request to Vision Eye Institute and I am aware that an administrative fee may be incurred.
• I am aware that Vision Eye Institute has the ability to send correspondence to my current referrer electronically and that every effort will be made to ensure the security of my data.
• I agree to receiving electronic correspondence to the email address and mobile phone number provided on this form.
• I understand that correspondence or data relating to my care may be sent to relevant health authorities.
• I understand that an observer may be present during my consultation/procedure and that my medical treatment will remain confidential.

I give permission for my carer/relative/friend to discuss my personal information (e.g. appointments, invoices, medical information) with clinic staff and I give permission for Vision Eye Institute to provide this information to my carer/relative/friend.

Vision Eye Institute is a private ophthalmology clinic and there will be costs associated with your appointment that relate to diagnostic testing required by your doctor to assess your eyes. The cost of these tests is not always claimable through Medicare and is payable in full on the day of the appointment. Consultation fees are eligible for a Medicare rebate if you have a current referral letter from your GP or optometrist.

By signing this form, you acknowledge that fees are payable on the same day.

Please advise staff if you do not agree to any of the above.