Online Referral Form

    Urgency of referral

    Urgent < 24-48hrs< 2 weeksNext available

    Patient Information

    Referrer’s Information

    Cataract/Refractive Surgery

    Refractive outcome preferable:

    Distance (Monofocal/Toric IOL)Near visionMonovisionRequires further discussion with surgeon

    Retinal

    Diabetic Eye reviewMacular DegenerationArtery/Vein OcclusionFlashes and Floaters

    Cornea Management

    Abrasion/UlcerKeratoconus/ectasiaPterygiumFuchs’ dystrophy / cornea dystrophyForeign body

    Glaucoma Assessment

    Narrow angleRaised IOPSuspicious ONH or C/D asymmetryVisual Field defectLaser Rx (iridotomy/SLT)

    IOP

    Additional Information


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