REFERRAL FORM FOR CLINICIANS

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Referrer Details

Referrer *

OptometristOphthalmologistGeneral Practitioner

Is this referral for a refractive consult? *

YesNo

Name *

Practice Name *

Provider Number *

Practice Phone *

Patient Details

Name *

Phone number *

Email Address

Date of Birth *

Street address *

City *

State *

Postcode *

Referral Information

Referral To

Dr Erica Darian-Smith (refractive, cataract, corneal surgery and general ophthalmology)Dr Mitchell Lee (vitreoretinal, medical retina, cataract surgery and general ophthalmology)Dr Noor Ali (glaucoma, uveitis, cataract surgery and general ophthalmology)

Reason for referral *

Relevant Medical History

What are the patients refractive laser/surgery goals?

General Health

History of autoimmune or connective tissue disease

List of Medications

Clinical Examination

Refraction Date

Current Script Right

Current Script Left

Right Uncorrected Acuity

Left Uncorrected Acuity

Best Corrected Acuity Right

Best Corrected Acuity Left

Subjective Refraction Right

Subjective Refraction Left

Central Corneal Ks Right

Central Corneal Ks Left

Intraocular Pressure Right

Intraocular Pressure Left

Corneal & Conjunctival Appearance

Corneal Scars or OpacitiesAbnormal Corneal VascularisationPunctate Fluorescein Staining

Details of any abnormality

Dilated Fundus Examination

Disc NormalMacula Normal

Details of any abnormality

Signature *

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Date *

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