For Referrers

You may send your referral by:

Filling in the below online form
Fax: 03 9115 7616
Digital Oculo integration

Referral pads may be obtained for use in your facility. Please contact our office to arrange for delivery.

Urgent referrals should be marked ‘FOR URGENT TRIAGE’. If you feel an urgent appointment is required in a very short time frame please contact our office directly.

Our surgeons may be free to discuss an urgent case if you require our assistance.

"*" indicates required fields

Patient Information

Name*

First Last

Email*

Mobile Phone*

Date of Birth*

Day

Month

Year

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Medicare*

expiry*

Clinical notes

Clinic notes

Investigation

Cataract

Pterygium

Glaucoma

Oculoplastics

Macular Degeneration

Diabetic Retinopathy

Retinal Vascular Disease

Intra-vitreal injections

Dry Eye

Tear Duct Surgery

Laser Vision Correction

Referring Doctor

Referrer name

Referrer address

Referrer phone

Provider Number

Document upload

File

Max. file size: 100 MB.

Comments

This field is for validation purposes and should be left unchanged.