Health Adms Solutions: Eye Hospital: PATIENT REFERRAL FORM

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:

Refraction and BCVA: Date: ____/____/______;\

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)

_____________________________________________________________________________________________________

Consultant Name:

Consultant Sign:

Health Adms Solutions