Consent Form for Eye Test & Hearing Screening at School

Did you know that 60% of children identified as "problem learners" are challenged by poor vision?

Good vision is essential for a child’s educational, social and physical development, and yet, approximately 1 in 5 children are suffering from undetected vision problems. Often children continue to persist through these viewing difficulties thinking that what they are seeing is normal.

The eye care professionals (optometrists, orthoptists and optical dispensers) at Improve Eyes Mobile Optometry will be coming to your child's school to conduct eye tests and hearing screenings. Our comprehensive eye checks and hearing screenings can detect problems early and manage them, so that we can ensure your child will have the best opportunities in the classroom.

Please fill in the form below if you would like your child to have their eyes tested and hearing screened at school.

Eye tests are bulk billed to Medicare which means tests are FREE for you and your child if eligible.

Privacy Statement: We value your privacy and are committed to protecting your personal information. Improve Eyes Pty Ltd only collect and use personal and health information necessary to provide appropriate health services. This means information may be disclosed to Service Australia (e.g. Medicare etc.), your child’s school in a report summary of results, other government agencies or relevant third party agencies to check, process claims and/or access vision/hearing services. View our Privacy Policy here.

Student Details

Student's first and middle name *(Please state as written on Medicare card)

Student's surname *(Please state as written on Medicare card)

Date of birth *

Gender *

FemaleMaleOther

Please Specify:

School *Select "other" if your school does not appear on this list

Please Specify Which School: *

Class *

Medicare card sample to use as reference

Medicare card number *(If none, fill in N/A)

Medicare reference number *(If none, fill in N/A)

Medicare expiry date *(If none, fill in N/A)

Is your child under the NDIS? *

Yes, self-managedYes, plan-managedYes, NDIA-managedNo

What is your main concern for your child's vision/sight? *

Does your child currently wear glasses/contact lenses? If yes, what do they use it for? *

Is there anyone in the family with an eye condition that they are seeing an eye specialist for? *

Does your child have any allergies or medical conditions? *

Is your child taking any ongoing medication or treatment? *

Parent/guardian's consent (vision)

I, parent/guardian, give consent for my child to receive a comprehensive eye test at school and agree to assign my right to benefits to the Practictioner(s) at Improve Eyes Pty Ltd who will render the optometry service(s) and bulk bill to Medicare. *

If my child is not eligible for Medicare, I, parent/guardian, give consent for my child to receive a comprehensive eye test at school by the team at Improve Eyes Pty Ltd and agree to a payment of $71.50 (Incl. GST).

Consent Form for Eye Test & Hearing Screening at School

We have now expanded our service to bring hearing screenings directly to your child at school!

We're conducting OPTIONAL hearing screenings at school which is not covered under Medicare or Private Health Insurance. There is a fee of $49.50 to opt in. You can skip this and proceed with a bulk billed eye check which is FREE for you.

Did you know? Even mild hearing difficulties can affect learning, attention and classroom participation. Get some peace of mind and give your child the best opportunities and success in learning!

Improve Eyes Pty Ltd are partners with Sound Scouts to deliver hearing screenings and hence are subjected to their terms and conditions and privacy policies.

Hearing Screening

Parent/guardian's consent (hearing screening) *

I, parent/guardian, give consent for my child to receive a hearing screen at school for $49.50 (Incl. GST).No, I do not consent to a hearing screening.

To register for the hearing screening for your child at school, please pay via our payment link below.

Skip this section if you do not consent to the hearing screening for your child.

Hearing payment of $49.50 (to opt in):

Pay

Consent Form for Eye Test & Hearing Screening at School

Photography/Filming and Publishing Consent Form

As part of our mobile optometry services at your child’s school, Improve Eyes Pty Ltd may take photographs or video recordings of students during our visit. All photography and filming will be conducted in line with the Privacy Act 1988 (Cth), the Health Records and Information Privacy Act 2002 (NSW), privacy laws and NSW Department of Education guidelines and relevant child protection legislation.

Conditions of use:
Images and videos may be used by Improve Eyes Pty Ltd only for educational, promotional and/or marketing purposes including using public platforms such as:

Social media platforms (e.g. Facebook, Instagram, TikTok, LinkedIn)
Our website and newsletters
Printed promotional material or reports
Educational materials to raise awareness of children’s eye health

Privacy & Protection:

Photographs and videos taken during school visits will not disclose sensitive identifiers such as student name, school name, location and/or health details without your explicit consent. Please be advised that photographs and videos are taken during school visits so school uniforms may appear in footage. Where possible, logos will be removed or covered before publishing.
Images will be securely stored, accessible only by authorised personnel, and used solely for the purposes outlined in this form.
No payment or compensation is provided for use of images or videos.
Where appropriate, students will also be told what the photography/filming is for, so they understand and can choose whether to participate.

Withdrawal of Consent:

You have the right to request access to or withdraw consent for the use of your child’s image/video at any time by contacting us in writing via our email available at the end of this consent form.
If consent is withdrawn, we will take reasonable steps to delete the content from our own accounts and stop using the images/videos. However, you acknowledge that once material has been published online or shared by third parties, Improve Eyes Pty Ltd cannot guarantee full removal/permanent deletion of publicly posted items from the internet or that all copies will be deleted.

Checking NO to this section does not prevent your child from receiving our on-site optometry or hearing services.

Consent to media publishing *

YES, I give permission for Improve Eyes Pty Ltd to photograph and/or film my child during their school visit. I understand these images may be used for promotional purposes and educational purposes described above. I am aware that I can withdraw my consent at any time by writing to Improve Eyes Pty Ltd.NO, I do not give permission for my child to be photographed or filmed.

Parent/guardian's full name *

Relationship with child *

Mobile *

Email *

Address *

City *

State *

Postcode *

Declaration *

YES. I confirm that I am the legal parent/guardian of the child named above and that I have read and understood the entirety of this consent form.

Signature: *

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