Referral  to Optometry
<Letterhead>

Date: <TodaysDate>
Optometrist Name <AdrDetails>

Re: Referral of Patient Name for an eye health check 

Thank you for seeing the following patient for assessment of their eye health. 

Patient Details:
Patient Name:<PtFullName>
Date of Birth:<PtDoB>
Address:<PtAddress>
Contact number:<PtPhoneMob><PtPhoneH>

Referral Details: 
Concerned about (Please tick) 
☐<Visual Fields> Visual Fields		☐ <Glaucoma>Glaucoma 			
☐ <Macular>Macular degeneration
☐<Visual Acuity	> Visual Acuity		☐ <Diabetic retinopathy	>Diabetic retinopathy		☐ <Cataract>Cataract
Other: <Others>______________________________________ 

Clinical reason for referral (symptoms, duration, severity):

<symptoms, duration, severity>

Additional relevant medical history that may assist in your review of the patient includes:

<Additional relevant medical history>

Current medications: 
<CurrentRx>

I look forward to receiving your written report regarding this patient upon completion of the examination. 

Yours sincerely, 

Referrers name 
<DrFirstName> <DrSurname>
<DrAddress>
Provider No: <DrProviderNo>