GP REQUEST FOR CONSULTATION
OPTOMETRY

SEND TO:
<<Preferred Optometrist's Name>>
Optometrist	FROM: <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>  
Fax: <<Practice:Fax>>      
Email: <<Doctor:E-mail>>   
Provider Number: <<Doctor:Provider Number>>
Signature	

Date: <<Miscellaneous:Date (long)>>
Dear Optometrist	

RE: <<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Sex>>
Medicare Number*: <<Patient Demographics:Medicare Number>>  *[Medicare ineligible patients will incur an appointment fee]
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Alternative Contact Name: <<Alternative contact name>>
Alt. Contact’s Phone: <<Alternative Contact Phone Number>>
[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:	
<<Clinical Details:History List>>	
Allergies:	
	
Current Medications:	
<<Clinical Details:Medication List>>	
Results:	
<<Summary:Investigation Results (Selected)>>