Referral  to Optometry
<<Practice/Location:Name>>
<<Doctor:Full Address>>
Fax: <<Practice/Location:Fax>>
<<Addressee:Name>>
<<Addressee:Full Address>> 
Email: <<Addressee:E-mail>>
Fax: <<Addressee:Fax>>
 
Date: <<Miscellaneous:Date (short)>>

Re: Referral of <<Patient Demographics:Full Name>> for an eye health check 

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

Patient Details:
Patient Name:<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:<<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
Contact number: <<Patient Demographics:Phone (Mobile)>>

Concerns about:
Visual acuity: <<Visual acuity concern>>	Macular degeneration:   <<Macular degeneration concern>>	
Visual fields:  <<Visual fields concern>>	Diabetic retinopathy:  <<Diabetic retinopathy concern>>	
Glaucoma: <<Glaucoma concern>>	Cataract: <<Cataract concern>>	
Other concern: <<Other concern: >>		
   		 
Clinical reason for referral (symptoms, duration, severity):
<<Reason for referral including symptoms, duration>>

Additional relevant medical history that may assist in your review of the patient includes:
<<Clinical Details:History List>>

Current medications: 
<<Clinical Details:Medication List>>

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

Yours sincerely, 

<<Doctor:Name>>
Provider No: <<Doctor:Provider Number>>