Dry Eye Clinic Referral Form
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Date
Practice address and phone number
Patient first name
Patient surname
Patient Date of Birth
Patient address
Patient phone number
Date of last full eye exam
Refraction (OD, VA, OS, VA)
Does the patient have signs of dry eye?
Yes
No
Please specify
Does the patient have symptoms of dry eye?
Yes
No
Please specify
Reasons for referral to the UNSW Dry Eye Clinic
Diagnosis only
Diagnosis and management
Ongoing management for dry eye
Specific tests
Relevant clinical findings
Relevant history
Referring clinician
Provider number
Clinician Signature
Sign above
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