EYE CLINIC, Prince of Wales Hospital
Level 4, High Street
Randwick NSW
Ph: (02) 9382 2261   Fax: (02) 9382 2281	Patient Referral Form	

Assessment for Cataract Surgery	

Outpatient Clinic use only	

Referral received:	
/	
/	

Referrer notified of receipt:	
/	
/	

		Referral to:	

	

Patient / client details

Patient name:	Address:	

	
Title:			
Medicare number:		Date of birth:		
Sex/gender:	Not Stated		
Phone:	W (work)H (home)M (mobile)	
Email:	None recorded.	Communication preference:
Phone W  o Phone H  o Phone M  o Email  o	
Carer name (if appropriate):	Phone:	

Email:	

	
Identifies as of Aboriginal or Torres
Strait Islander origin:		Interpreter required:
Language:None Recorded.	Yes   o	No o	
Special needs/reasonable adjustments
required for disability:	Yes   o	No o	Description of required adjustments:	
GP name (if not referrer):	Optometrist name (if not referrer):	
Phone:		Phone:		
Email:		Email:		
Please confirm that the patient understands they are being referred for assessment of their cataract for surgery	o	
Clinical details
Best correct visual acuity (BCVA)	Right eye………… Left eye………………
To be completed by GP or an optometrist	Date 		
Level of difficulty experienced by patient due to sight issues:	No difficulty o Some difficulty o Moderate difficulty o Extreme difficulty o
E.g. Recognising faces, reading newspaper text or TV subtitles, seeing to walk on uneven surfaces	
Patient’s driving status:	Has driving licence   o Drives professionally  o Does not have driving licence   o
	
Falls experienced by patient in past year:	Two or more  o	Less than two  o	None o
A fall can be described as an unexpected event in which the patient has come to rest on the ground, floor, or lower level	
Any previous surgery for cataracts:	Yes   o	Description: 
Right eye   o 
Left eye     o	No o
	
Any other co-existing conditions:	Yes   o	Amblyopia   o	Diabetes  o Glaucoma o Only functioning eye  o  Other o  	No o	
Any current medication:	Yes   o	Description and dosage:	No o	

Referrer details

Name:	
Optometrist  o	
Ophthalmologist   o	
GP  o	
Provider
number:		Phone:		
Email:		Fax:		
Signature:		Date:		
Other details if required