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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