Get Optometrist Referral Form

OPTOMETRIST REFERRAL FORM Optometrist to FAX to CFEH 02 8115 0799 Patient Contact Details Title Dr Mr Miss Ms Other Email Assistance Requested Wheelchair Mobility Language Interpreter Yes If yes please specify language Hearing Interpreter Accommodation Transportation Surname / Mailing Address Suburb Postcode State Client Appointment Preference please tick Patient Clinical Details Home or Work Mobile First Name Date of Birth Phone Mrs Conditions Mon Tues No apply. Wed Thurs AND Fri AM or PM Note Urgent Referrals should not be sent to the Centre 6/ Refraction and BCVA Compulsory Date Primary reason for referral Pertinent exam findings Is the patient currently under ophthalmological care Ophthal Name No If yes complete below Condition Treated Last Consult Date Please select EITHER Option 1 OR Option 2 OPTION 1 Imaging and Visual Function Services. Please select up to 5 individual tests. Posterior Eye Pole Macula ONH Optomap/Retinal Photography o 5 Fields Specific Location B-Scan Ultrasound specify HRT3 ONH OCT select type ON Autoflourescence Anterior Eye Tests of Visual Function Acquired Colour Vision select Confocal Microscopy select type D-15 De-Sat D-15 100 Hue Endothelial Cell Count Sahlgren s FDT Matrix OR Humphrey VFA Corneal Topography select type select Pentacam HR Medmont E300 24-2 30-2 10-2/Macula Pentacam other Anterior OCT details Electrophysiology select type ERG VEP EOG UBM details Biometry IRX3 Lenstar Pachymetry OPTION 2 Ocular Condition Assessment. Please select one Provide a referral letter if space above is insufficient. Pigmented Lesion Retinal Dystrophy Cornea Diabetic Retinopathy Peripheral Retina DFE must have already been performed Glaucoma Optic Nerve not glaucoma Referring Practitioner Details must be completed In signing this referral form I agree to abide by CFEH Referring Practitioner Terms and Conditions outlined on the Practitioner Registration Form* Medicare Provider No Date Version 1015-07-2013. Wed Thurs AND Fri AM or PM Note Urgent Referrals should not be sent to the Centre 6/ Refraction and BCVA Compulsory Date Primary reason for referral Pertinent exam findings Is the patient currently under ophthalmological care Ophthal Name No If yes complete below Condition Treated Last Consult Date Please select EITHER Option 1 OR Option 2 OPTION 1 Imaging and Visual Function Services. Please select up to 5 individual tests. Posterior Eye Pole Macula ONH Optomap/Retinal Photography o 5 Fields Specific Location B-Scan Ultrasound specify HRT3 ONH OCT select type ON Autoflourescence Anterior Eye Tests of Visual Function Acquired Colour Vision select Confocal Microscopy select type D-15 De-Sat D-15 100 Hue Endothelial Cell Count Sahlgren s FDT Matrix OR Humphrey VFA Corneal Topography select type select Pentacam HR Medmont E300 24-2 30-2 10-2/Macula Pentacam other Anterior OCT details Electrophysiology select type ERG VEP EOG UBM details Biometry IRX3 Lenstar Pachymetry OPTION 2 Ocular Condition Assessment. Please select up to 5 individual tests. Posterior Eye Pole Macula ONH Optomap/Retinal Photography o 5 Fields Specific Location B-Scan Ultrasound specify HRT3 ONH OCT select type ON Autoflourescence Anterior Eye Tests of Visual Function Acquired Colour Vision select Confocal Microscopy select type D-15 De-Sat D-15 100 Hue Endothelial Cell Count Sahlgren s FDT Matrix OR Humphrey VFA Corneal Topography select type select Pentacam HR Medmont E300 24-2 30-2 10-2/Macula Pentacam other Anterior OCT details Electrophysiology select type ERG VEP EOG UBM details Biometry IRX3 Lenstar Pachymetry OPTION 2 Ocular Condition Assessment. Please select one Provide a referral letter if space above is insufficient. Pigmented Lesion Retinal Dystrophy Cornea Diabetic Retinopathy Peripheral Retina DFE must have already been performed Glaucoma Optic Nerve not glaucoma Referring Practitioner Details must be completed In signing this referral form I agree to abide by CFEH Referring Practitioner Terms and Conditions outlined on the Practitioner Registration Form* Medicare Provider No Date Version 1015-07-2013.