GP REQUEST FOR CONSULTATION
OPTOMETRY
    
SEND TO:
Optometrist
Optometrist	FROM: Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone 
Fax: Practice.Fax  
Email: Treating Doctor.E-mail  
Provider Number: Treating Doctor.Provider Number
Signature	

Date: Miscellaneous.Date
Dear Optometrist	

RE: Patient Demographics.Full Name
DOB:  Patient Demographics.DOB
Gender:  Patient Demographics.Gender
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: Patient Demographics.Emergency Contact Name
Alternative Contact Phone: Patient Demographics.Emergency Contact Home Phone 
[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: Language 
Reason for Referral

 Reason for Referral

Key examination findings:

Key exam findings

Management provided to date:

Management provided

	

Previous Diagnosis:
   Cataract:  Cataract
   Glaucoma:  Glaucoma
   Macular Degeneration:  Macular Degeneration
   Other:  Other
PLEASE PROVIDE VISUAL ACUITY 
SNELLEN (or equivalent) VISUAL ACUITY
Right: Snellen right
Left: Snellen Left
Both:Snellen Both
	
Relevant Medical History: 	
Clinical Details.Problem List (Current)	
Allergies:	
Clinical Details.Allergies	
Current Medications:	
Clinical Details.Medications - Current Regular	
PLEASE ENSURE APPROPRIATE PRE-REQUISITE TESTS HAVE BEEN PERFORMED AND ARE ATTACHED.	
	
Results:	
Clinical Details.Result List (Selected)