GP REQUEST FOR CONSULTATION
OPTOMETRY

SEND TO:
<Preferred Optometrist's Name>
Optometrist
	FROM: <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>
Signature 	

Date: <TodaysDate>
Dear Optometrist	
RE:<PtFullName>
DOB: <PtDoB>
Gender: <PtSex>
Medicare Number*: <PtMCNo> *[Medicare ineligible patients will incur an appointment fee]
Address: <PtAddress>
Home Phone: <PtPhoneH>
Mobile Phone: <PtPhoneMob>
Alternative Contact Name: <NOKName>
Alternative Contact's Phone: <NOKContact>
[Alternative contact may be used to contact the patient if they cannot be reached via the contact details given]
Interpreter Required: <Interpreter Required>     Please specify Language: <Please specify Language>
Reason for Referral
<Reason for Referral>
Key examination findings:
<Key examination findings>
Management provided to date:
<Management provided to date>
Previous Diagnosis:
   Cataract: <Previous Diagnosis - Cataract>
   Glaucoma:  <Previous diagnosis - Glaucoma>
   Macular Degeneration:  <Previous diagnosis - Macular Degeneration>
   Other:  <Previous diagnosis - Other>
PLEASE PROVIDE VISUAL ACUITY
SNELLEN (or equivalent) VISUAL ACUITY
Right: <SNELLEN (or equivalent) VISUAL ACUITY - Right>
Left: <SNELLEN (or equivalent) VISUAL ACUITY - Left>
Both: <SNELLEN (or equivalent) VISUAL ACUITY - Both>	
Relevant Medical History:	
<PMHAll>	
Allergies:	
<Reactions>	
Current Medications:	
<CurrentRx>	
Results:	
<Ix>