The details you provide will enable us to better identify the patient's needs so we can tailor our service to their requirements.
I acknowledge that this information is accurate to the extent that I can be certain, and will disclose additional information as necessary. This information can only be used in the management of the patient.
I confirm I have consent from the patient to provide their information to OCULA, and that OCULA has patient permission to contact them to arrange an appointment.
MINOR PATIENTS: In providing this information, I attest that to the best of my knowledge the parental guardian listed in this form is the legal guardian authorised to make appointments for the minor. (Note: This legal guardian will be required to complete a final declaration of right to have the minor treated at our facility)
The team at OCULA