PATIENT REFERRAL FORM
Referral Date: ____/____/______
Referral addressed to: Dr _______________________
Clinic/ Hospital Name: __________________________
Referrer’s Signature: ___________________________
Referrer’s Name:
______________________________
Patient - Contact Details:
Patient Name: _______________________________________
UHID No: _________________________________________
Mobile number: ______________________________________
Email address: _______________________________________
Address:
_____________________________________________
Reason for Referral: _______________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Ocular Condition Assessment (Please select one):
CATARACT SURGICAL RETINA AND MACULA
GLAUCOMA CORNEA & ANTERIOR SEGMENT
DIABETES DIABETIC RETINOPATHY
PAEDIATRICS SQUINT
NEURO-OPHTHALMOLOGY
Patient – Clinical Details:
R:__________________ 6/______; L:
__________________ 6/______
Other Relevant Exam
Findings: ___________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Relevant Eye Conditions for
Referral of Patient: Previous Lasik
Surgery; Previous Eye Surgery; Other (please specify)
Relevant Medical Conditions
for referral of Patient: Diabetes; Other (please specify)