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Eye Institute | Laser Eye Surgery and Eye Health Logo Eye Institute | Laser Eye Surgery and Eye Health Logo Eye Institute | Laser Eye Surgery and Eye Health Logo
  • VISION CORRECTION
    • Laser Eye Surgery
      • Laser Eye Surgery Overview
      • SMILE
      • LASIK
      • PRK
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      • Pricing & Financing
      • Out of Town Offer
      • Laser Eye Surgery – FAQs
    • Refractive Surgery
      • Refractive Lens Exchange
  • WHO WE HELP
    • Symptoms
      • Blurred Vision
      • Contact Lens Problems & Irritation
      • Double Vision
      • Droopy Eyelids
      • Dry Eyes
      • Eyelash Problems
      • Eye Floaters & Flashes
      • Sore Eyes
      • Sudden Blindness
      • Tunnel Vision
      • Watery Eyes
    • Conditions
      • Age-related Macular Degeneration
      • Astigmatism
      • Cataract
      • Diabetic Retinopathy
      • Glaucoma
      • Keratoconus
      • Long Sightedness
      • Macular Hole
    • More Conditions
      • Posterior Capsule Opacity
      • Presbyopia
      • Pterygium & Pinguecula
      • Ptosis Of The Eyelid
      • Retinal Detachment
      • Retinal Vein Occlusions
      • Short Sightedness
      • Sjögren’s Syndrome
      • Vitreous Haemorrhage
  • WHAT WE DO
    • Treatments
      • Cataract Treatment
      • Corneal Implants
      • Corneal Transplant Surgery
      • Diabetic Retinopathy Treatment
      • Dry Eye Clinic
      • Dry Eye Treatment
      • Epiretinal Membrane
      • Eyelid Surgery
      • Glaucoma Treatment
      • Keratoconus Treatment
    • More Treatments
      • Macular Degeneration Treatment
      • Pterygium & Pinguecula Treatment
      • Refractive Cataract Surgery
      • Retinal Detachment Surgery
      • Retinal Vein Occlusion Treatment
      • Vitrectomy
      • YAG Laser Capsulotomy
    • Eye FAQs
      • How the Eye Works
      • Eye Care FAQs
      • How to use Eye Drops
  • ABOUT US
    • Our Surgeons
      • Dr Ammar Binsadiq
      • Dr William Cunningham
      • Dr Kevin Dunne
      • Professor Dame Helen Danesh-Meyer
      • Dr Narme Deva
      • Dr Stef Guglielmetti
      • Dr Sophie Hill
      • Dr Peter Hadden
      • Dr Edward Hutchins
      • Dr Liz Insull
      • Dr Brian Kent-Smith
      • Dr Vipin Kuriachan
    • Surgeons
      • Dr Nick Mantell
      • Dr Kaliopy Matheos
      • Prof Charles McGhee
      • Dr Jay Meyer
      • Dr Graham Reeves
      • Dr Peter Ring
      • Dr Baswati Sahoo
      • Dr Shira Sheen
      • Dr Rona Silkiss
      • Dr Shanu Subbiah
      • Dr Adam Watson
    • About Us
      • Blog
      • Community Trust
      • Meet The Eye Surgeons
      • Meet the Senior Leadership Team
      • Pricing & Financing
      • Work for Eye Institute
      • Technologies & Facilities
  • BOOK A FREE LASER ASSESSMENT
    • Book a free laser assessment
    • Book a non-laser appointment
  • VISION CORRECTION
    • Laser Eye Surgery
      • Laser Eye Surgery Overview
      • SMILE
      • LASIK
      • PRK
      • LASIK Alternative
      • Pricing & Financing
      • Laser Eye Surgery – FAQs
    • Refractive Surgery
      • Refractive Lens Exchange
  • WHO WE HELP
    • Symptoms
      • Blurred Vision
      • Contact Lens Problems & Irritation
      • Double Vision
      • Droopy Eyelids
      • Dry Eye Clinic
      • Dry Eyes
      • Eye Floaters & Flashes
      • Eyelash Problems
      • Sore Eyes
      • Sudden Blindness
      • Tunnel Vision
      • Watery Eyes
    • Conditions
      • Age-related Macular Degeneration
      • Astigmatism
      • Cataract
      • Diabetic Retinopathy
      • Glaucoma
      • Keratoconus
      • Long Sightedness
      • Macular Hole
      • Posterior Capsule Opacity
      • Presbyopia
      • Pterygium & Pinguecula
      • Ptosis Of The Eyelid
      • Retinal Detachment
      • Retinal Vein Occlusions
      • Short Sightedness
      • Sjögren’s Syndrome
      • Vitreous Haemorrhage
  • WHAT WE DO
    • Treatments
      • Cataract Treatment
      • Corneal Implants
      • Corneal Transplant Surgery
      • Diabetic Retinopathy Treatment
      • Dry Eye Clinic
      • Dry Eye Treatment
      • Epiretinal Membrane
      • Eyelid Surgery
      • Glaucoma Treatment
      • Keratoconus Treatment
      • Macular Degeneration Treatment
      • Pterygium & Pinguecula Treatment
      • Refractive Cataract Surgery
      • Retinal Detachment Surgery
      • Retinal Vein Occlusion Treatment
      • Vitrectomy
      • YAG Laser Capsulotomy
    • Eye FAQs
      • How the Eye Works
      • Eye Care FAQs
      • How to use Eye Drops
  • ABOUT US
    • Our Surgeons
      • Dr Ammar Binsadiq
      • Dr William Cunningham
      • Dr Kevin Dunne
      • Professor Dame Helen Danesh-Meyer
      • Dr Narme Deva
      • Dr Stef Guglielmetti
      • Dr Sophie Hill
      • Dr Peter Hadden
      • Dr Edward Hutchins
      • Dr Liz Insull
      • Dr Brian Kent-Smith
      • Dr Vipin Kuriachan
      • Dr Nick Mantell
      • Dr Kaliopy Matheos
      • Prof Charles McGhee
      • Dr Jay Meyer
      • Dr Graham Reeves
      • Dr Peter Ring
      • Dr Baswati Sahoo
      • Dr Shira Sheen
      • Dr Rona Silkiss
      • Dr Shanu Subbiah
      • Dr Adam Watson
    • About Us
      • Blog
      • Community Trust
      • Meet The Eye Surgeons
      • Meet the Senior Leadership Team
      • National & International Patients
      • Pricing & Financing
      • Work for Eye Institute
      • Technologies & Facilities
  • BOOK A FREE LASER ASSESSMENT
  • BOOK A NON-LASER APPOINTMENT
New Patient FormRobyn Chambers2021-12-10T15:21:44+00:00

New patient form

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Please confirm your current Covid-19 vaccination status*
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Name*
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Name of Medical Insurer

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Consent for the use of clinical scans and photographs

I agree for my clinical scans and/or photographs to be*: *all scans/photographs will be non-identifiable
1. Stored electronically for an indefinite period of time for the use related to my clinical care
2. Potentially used in presentation and publications for the purpose of teaching, assessment and/ or research
*Must have parental responsibility for the child
DD slash MM slash YYYY

Interpreter’s statement (if applicable)

I declare that I have interpreted the above information to the patient to the best of my ability and in a way which I believe he/she can understand
OUR LOCATIONS
Our Locations

Whangarei

  • 19 Kamo Road, Whangarei
  • Phone:0800 437 1160
  • Whangarei@eyeinstitute.co.nz
  • Find out more

Central: Remuera

  • 123 Remuera Road, Remuera, Auckland 1050
  • Phone: 0800 99 2020 or 09 522 2125
  • Fax: 09 529 1814
  • enquiries@eyeinstitute.co.nz
  • Find out more

North: Northcote

  • 3 Akoranga Drive, Northcote, Auckland 0627
  • Phone: 09 443 3212 
  • Fax: 09 443 3210
  • north@eyeinstitute.co.nz
  • Find out more

West: New Lynn

  • 19 Delta Avenue, New Lynn, Auckland 0600
  • Phone: 09 827 2121 
  • Fax: 09 529 1814
  • west@eyeinstitute.co.nz
  • Find out more

South: Manukau

  • 652 Great South Road, Manukau, Auckland 2104
  • Phone: 09 262 3020 
  • Fax: 09 262 3080
  • south@eyeinstitute.co.nz
  • Find out more

South: Surgery location

  • 652 Great South Road, Manukau, Auckland 2104
  • Phone: 09 262 3020 
  • Fax: 09 262 3080
  • south@eyeinstitute.co.nz
  • Find out more

Hawke's Bay

  • 209 Canning Road, Camberley, Hastings 4120
  • Phone: 06 974 6664 
  • hawkesbay@eyeinstitute.co.nz
  • Find out more

Wellington

  • Bell Gully Building, Level 1, 40 Lady Elizabeth Lane, Wellington Central, Wellington 6011
  • Phone: 04 550 2300  
  • Wellington@eyeinstitute.co.nz
  • Find out more

Blenheim

  • Eye Institute Blenheim, Churchill Specialist Centre, Gate 2, Hospital Road, Blenheim 7201
  • Phone: 03 520 9960
  • specialist@churchillhospital.co.nz
  • Find out more

Dunedin

  • 43 Filleul Street, Central Dunedin, Dunedin 9016
  • Phone: 03 9513 779
  • Dunedin@eyeinstitute.co.nz
  • Find out more
OUR POPULAR PROCEDURES
  • SMILE
  • LASIK
  • Refractive Lens Exchange
  • Refractive Cataract Surgery
TAKE A STEP TO FREEDOM

Discover if you could be free from the hassle of glasses and contacts.

Take the first step by getting your free laser suitability assessment to check if your eyes are suitable and which treatment option is right for your eyes.

GET YOUR FREE LASER ASSESSMENT

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