Practitioner Registration Form
To refer to Centre for Eye Health, you must first register. Registration is free and simply involves completing the following details, reviewing our terms and conditions and returning the signed form. Once registered, you will be sent a referrer information pack. NOTE: If you are already registered with CFEH and wish to change your details, please complete the Practitioner Change of Details form: https://www.centreforeyehealth.com.au/wp-content/uploads/2018/12/Registered-Practioner-Change-of-Details-v4_May-2013.pdf
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Title: *
First Name: *
Last Name: *
Mobile: *
Email: *
For optometrists: *
Primary Practice Name (Note: Locums do not need to complete): *
Primary Practice address: *
Primary Practice Phone: *
Primary Practice Email: *
Primary Practice Medicare Number: *
Does this Practice have any of the following Instruments?  *
Required
OCT- If YES- Please specify Model below (Eg. Cirrus, Topcon, Nidek)
PERIMETER (Visual Fields)- If YES -Please specify Model below (Eg. HFA, Matrix, Medmont)
 *
Secondary Practice Name (Optional) (Note: Locums do not need to complete):
Secondary Practice address:
Secondary Practice Phone:
Secondary Practice Email:
Secondary Practice Medicare Number:
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