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:<<Patient Demographics:Full Name>>	Address:<<Patient Demographics:Full Address>>	

	
Title:	<<Patient Demographics:Title>>		
Medicare number:	<<Patient Demographics:Medicare Number>>	Date of birth:	<<Patient Demographics:DOB>>	
Sex/gender:	<<Patient Demographics:Gender>>		
Phone:	W (work)<<Patient Demographics:Phone (Work)>>H (home)<<Patient Demographics:Phone (Home)>>M (mobile)<<Patient Demographics:Phone (Mobile)>>	
Email:	<<Patient Demographics:E-mail>>	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:	<<Patient Demographics:ATSI>>	Interpreter required:
Language:<<Patient Demographics:Language Spoken>>	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 		
When wearing glasses the patient can:	Recognise faces o Read newspaper text or TV subtitles o          See to walk on uneven surfaces o 	
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