Parents' Full  Name
Address
Phone number:
Email
Your child's name
\
 \
Your child's date of birth (DD/MM/YYYY)
Please tick the appropriate box

Which of the following does your child wear for the correction of their eyesight:
Spectacle
 Contact lenses
 Both
 None
How long ago was your child's most recent eye
examination:
years
 months
Please supply their most recent prescription (if available):
Right Eye
 Left Eye
Does your child wear eyesight correction for:
Astigmatism
Myopia (short sightedness)
Not sure
Hyperopia (long sightedness)
For how long has your child been wearing vision correction:
Spectacles
 years
 months
Frequency
 Constant
 Occasionally
 Rarely
Contact lenses
 years
 months
Frequency
 Constant
 Occasionally
 Rarely
Has your child worn hard (rigid gas permeable or RGP) contact lenses?
Yes
 No
Does your child suffer (or has he/she suffered from any of the following eye
conditions? (Please tick the box):
Keratoconus
 Allergic/infectious conjunctivitis    
Corneal dystrophies
 Corneal infections    
Eye lid infection
Previous eye surgery or trauma
Lazy eye        
Other (please describe)
Does you child suffer from any health conditions that require occasional or
constant medication?
No
Yes (please describe)
What is the ethnicity of your child?
Father
Mother
Mainland/Hong Kong Chinese
Singaporean
Taiwanese
Korean
Japanese
Other (please specify)
Although our research will be conducted by fully qualified optometrists, we do not
intend to replace the service provided by your child's optometrist/ophthalmologist.  
Therefore, we encourage you to maintain your child's schedule of regular eye
check-ups with their optometrist/ophthalmologist.
Please provide contact details of your child's current optometrist/ophthalmologist:
If your child is accepted into our studies, we would like to contact their current
optometrist/ophthalmologist to advise them of their participation, to request information
on your child's present and past spectacle/contact lenses prescription, and to provide
updates of their progress in orthokeratology
Name of optometrist/ophthalmologist:  
Address:
Telephone number:
Please include any comment or more information you would like to add (optional):
If you are interested in the Myopia Control Study, currently conducted by the ROK research group at
the School of Optometry and Vision Science, University of New South Wales, please fill in the form and
we will contact you shortly.  

If you would like to print the form, please download it from here. Complete the form and fax it to
(02)  9313 6243
Research in Orthokeratology Online Form