Fax to the Eye Clinic on 9540 8067	
The Eye Clinic
Sutherland Hospital
Kingsway
Caringbah NSW 2229	•	For administrative enquiries: phone 9540 7067
•	For urgent referrals, please contact the on-call Ophthalmology Registrar via switchboard 9540 7111	
This service provides diabetic retinopathy assessment with an emphasis on patients who are not currently receiving appropriate retinopathy screening as per clinical guidelines. Please avoid referring patients who are currently receiving appropriate screening by their ophthalmologist or optometrist. Patients who are undergoing treatment for diabetic retinopathy elsewhere should not be referred to this service. Please note: Depending on the nature and urgency of the referral, patients will be assessed on site by either the Ophthalmology Service or Centre for Eye Health.	
PATIENT INFORMATION
Title: <<Patient Demographics:Title>>
Surname: <<Patient Demographics:Surname>>	                 
First Name: <<Patient Demographics:First Name>>
Date of Birth: <<Patient Demographics:DOB>>   
Address: <<Patient Demographics:Full Address>>
 	Medicare Number:<<Patient Demographics:Medicare Number>> Ref # ______  Expiry: <<Patient Demographics:Medicare Expiry Date>>   
Phone Number: 
(home) <<Patient Demographics:Phone (Home)>>
(work) <<Patient Demographics:Phone (Work)>>
(mobile) <<Patient Demographics:Phone (Mobile)>>
Email:<<Patient Demographics:E-mail>>
o Interpreter required: Language__________________
o Aboriginal or Torres Strait Islander  	
CLINICAL INFORMATION 	
VISUAL SYMPTOMS/PAST OPHTHALMIC HISTORY 

☐ Has not received retinopathy screening in past 2 years (time since last screening  _______________)	
DIABETIC STATUS
☐ Type 1   ☐ Type 2   
Duration ______ years   
Control: Excellent / Good / Fair / Poor	
HbA1c ______   (date: _____________ )	OTHER RETINOPATHY RISK FACTORS 
☐ Hypertension   	Control: Excellent / Good / Fair / Poor
☐ Hyperlipidaemia
☐ Smoking	Current / Former
☐ Pregnancy
☐ Renal Dysfunction
☐ Other Diabetic Complications:______________________	
OTHER MEDICAL HISTORY (attach if required)
 	
MEDICATIONS (attach if required)
<<Clinical Details:Medication List>>	ALLERGIES
<<Clinical Details:Allergies/Adverse Reactions>>	
OTHER HEALTH CARE PROVIDERS	Endocrinologist ____________________________________
Optometrist _________________________________ 	Other____________________________________________	
REFERRING PRACTITIONER DETAILS
GENERAL PRACTITIONER 
Name: <<Doctor:Name>>
Address: <<Doctor:Full Address>>	Provider No.: <<Doctor:Provider Number>> 
Referral valid for: ☐ 12 months ☐ Other_____________
Referral Date: <<Miscellaneous:Date>> 
Signature: ________________________________________	
TSH Use 	Reg        VMO        CFEH		TF	  	Rev     /     /