Myopia Control Referral Form
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Patient Details
Name
Date of birth
Contact Number
Email
Address
How would the patient like to book their appointment?
UNSW to contact patient
Patient to contact UNSW
If unsure, select "UNSW to contact patient"
Reasons for Referral
Patient interested in (please select all that apply)
Atropine
Orthokeratology
Multifocal contact Lenses
Unsure/Not discussed yet
Other…
Enter other…
Additional comments
Significant Clinical Findings (from most recent eye examination):
Date of most recent eye examination
Subjective Refraction and BCVA
RE Subjective Refraction
RE Subjective Refraction
RE BCVA
RE BCVA
LE Subjective Refraction
LE Subjective Refraction
LE BCVA
LE BCVA
Additional Comments
Additional Comments
Previous Prescriptions (if available)
Date of Last Prescription
RE Subjective Refraction
RE Subjective Refraction
RE BCVA
RE BCVA
LE Subjective Refraction
LE Subjective Refraction
LE BCVA
LE BCVA
Additional Previous Prescriptions
Additional Comments (including current myopia control treatments)
Other exam findings (i.e. current myopia control treatments, binocular vision, ocular health etc.)
Please select preference
Assessment only
Assessment and Management
Assessment and Co-Management
Referrer's Details
Referrer Name
Referrer Practice Name
Referrer Practice Address
Referrer Practice Email
Practice Phone Number
Practice Fax Number
Referrer Medicare Provider Number
Signature (use touchscreen or cursor to sign)
Sign above
Leave this field blank