Early learning

Consent for eye examination

Lesley Stanich visits early learning centres to examine the children's eyes. Please complete this form so your child can be seen.

The examination is bulk billed to Medicare, so there is nothing to pay. It takes about a minute to fill in.

Fields marked * are required.

About your child

How we reach you

Please give us at least one of these, in case Lesley needs to speak to you about your child's eyes.

Medicare

Eye examinations are bulk billed, so we need the card your child is listed on.

Anything we should know

Consent

The eye examination will be carried out by Lesley Stanich, provider number 4972427F.

I assign my right to benefits to the Practitioner who will render the services.

Privacy note

The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of Australian Government health programs, and may be used to update enrolment records. Its collection is authorised by provisions of the Health Insurance Act 1973. This information may be disclosed to the Dept of Health and Ageing, Centrelink, other relevant agencies or to a person in the medical practice associated with this claim, or as authorised or required by law.