********** OptometristS REFERRAL FORM ****************


Salutation*Mr. Ms. Mrs. Dr. Prof. Mx.
City*
Zip*
Urgency*–None–Very urgent (Within 24 hours – please call 09 520 9135) Urgent (Within 2 weeks) Routine (2+ weeks)
Description
Preferred Clinic*–None–New Lynn Ormiston Pukekohe Remuera Takapuna
Preferred Doctor* –None– Next Available Consultant Aaron Wong Alison Pereira Archie McGeorge Bia Kim Chi-Ying Chou David Pendergrast Dean Corbett Joel Yap Justin Mora Rachael Niederer Riyaz Bhikoo Sarah Hull Sarah Welch Shenton Chew Sid Ogra Stephen Best Stuart Carroll Sue Ormonde Taras Papchenko Yvonne Ng
Assesment of* –None– Acute Cataract Clinical Research Trial Cornea Dry Eye Clinic Genetics Glaucoma Oculoplastics Other Paediatric Refractive Lens Exchange Retina Strabismus Uveitis
R):
VA:
Add+N:
L):
VA:
Add+N:
Appointment Made* Yes No
Referrer Type* –None– Optometrist General Practitioner Other (Please specify)
Referrer Name*
Practice Name*
Referrer Email*
Referrer Comments