EyeScreen Safeguarding your child's windows to the world Eyescreen™ Registration EyescreenTM Eligibility The child should be aged between 6 months to 6 years.not administered with any eye treatment or prescribed with glasses.has not been detected with any eye condition. Number of children to register - Select -12 For First Child Child's Full Legal Name Has your child been administered with any eye treatment or been prescribed with glasses? Yes No Location Mount Elizabeth Novena Hospital Date of Screening - Select - Time of Screening - Select - Child's Information Has your child used our Eyescreen service before? Yes No *We will require the last 3-digits+alphabet of your child's Birth Certificate No. for verification Child's Birth Certificate No. (Example - 000A) Child's Date of Birth Gender Boy Girl Child's Medical History Was your child born full term? Yes No If it was a premature birth, please indicate the gestation week delivered Was there any childbirth complication? Yes No It yes, please state: Has your child been diagnosed of any medical condition? Yes No It yes, please state: Has your child visited an eye/vision screening provider before? Yes No If yes, please state Cordlife / Eyescreen Hospital / Polyclinics Eye Clinics/ Optical Shop Pre-school/ Kindergarten Others please indicate: Hospital / Polyclinics please indicate: Eye Clinics/ Optical Shop Please Indicate: Others When was your child last eye/vision screening? Less than 6 months Between 6 -12 months More than 12 months What was your child's screening result from the last eye/vision screening? Normal / Passed Borderline / Under monitoring for the next review Diagnosed of having an eye condition / Under treatments/ Glasses prescription Others Please specify: Has your child been suspected of having any eye condition? Yes No If yes, please state Is there a family history of any eye condition? Yes No If yes, please state For Second Child Child's Full Legal Name Has your child been administered with any eye treatment or been prescribed with glasses? Yes No Location Mount Elizabeth Novena Hospital Date of Screening Time of Screening Child's Information Has your child used our Eyescreen service before? Yes No *We will require the last 3-digits+alphabet of your child's Birth Certificate No. for verification Child's Birth Certificate No. (Example - 000A) Child's Date of Birth Gender Boy Girl Child's Medical History Was your child born full term? Yes No If it was a premature birth, please indicate the gestation week delivered Was there any childbirth complication? Yes No It yes, please state: Has your child been diagnosed of any medical condition? Yes No It yes, please state: Has your child visited an eye/vision screening provider before? Yes No If yes, please state Cordlife / Eyescreen Hospital / Polyclinics Eye Clinics/ Optical Shop Pre-school/ Kindergarten Others please indicate: Hospital / Polyclinics please indicate: Eye Clinics/ Optical Shop Please Indicate: Others When was your child last eye/vision screening? Less than 6 months Between 6 -12 months More than 12 months What was your child's screening result from the last eye/vision screening? Normal / Passed Borderline / Under monitoring for the next review Diagnosed of having an eye condition / Under treatments/ Glasses prescription Others Please specify: Has your child been suspected of having any eye condition? Yes No If yes, please state Is there a family history of any eye condition? Yes No If yes, please state Parent’s/ Guardian’s information Are you a Cordlife client? Yes No *We will require your Date of birth, contact, and Email for verification Full Legal Name Mother's Date of Birth Contact Number Email Address Where did you hear about Eyescreen™? Referral from Paediatrician Referral from friends/Cordlifeclient Events/Roadshow Cordlife email Cordlife website Cordlife Facebook/YouTube Cordlife Investor Relations Website Online Forum Others Why did you enrol for Eyescreen™? Suspect my child has vision problem(s) Good to know/Try it out Family history of vision problem(s) Important to check Others EventsRoadshowName OnlineForumName OthersOptinName OthersEnrolName
