Practitioner Referral

Home About New Vision Practitioner Referral

Pre-Operative Refractive Report

Please fill in your details below. * Indicates a required field

Patient information

Patient's given name *

Patient's surname *

Address *

Postcode *

DOB *

Phone *

Occupation

Referring Optometrist *

Address *

Phone *

Email *

Provider Number *

Patients health

General medical health (enter details below)

Regular Medication

Any allergies? (enter details below)

Family History - medical and ocular

Past ocular history - medical and surgical

Examination information

Pre-Operative Refractive Report
Examination
Labels		Right (OD)	Left (OS)
Current spectacle refraction		Current spectacle refraction (OD)	Current spectacle refraction (OS)
Add - if applicable		Add - if applicable (OD)	Add - if applicable (OS)
If wearing contacts state type		If wearing contacts state type (OD)	If wearing contacts state type (OS)
Is refraction stable?		Yes No	Yes No
Current refraction (incl. BVD if >6 dioptres)		Current refraction (incl. BVD if >6 dioptres) (OD)	Current refraction (incl. BVD if >6 dioptres) (OS)
Visual acuity with current refraction		Visual acuity with current refraction (OD) 6 /	Visual acuity with current refraction (OS) 6 /
Keratometry (dioptres, axis)		Keratometry (dioptres) (OD)	Keratometry (dioptres) (OS)
Keratometry (dioptres, axis)		Keratometry (Axis) (OD)	Keratometry (Axis) (OS)
Slit lamp exam Any Abnormalities	Normal	Slit lamp exam Any Abnormalities (OD)	Slit lamp exam Any Abnormalities (OS)
Intraocular pressure		Intraocular pressure mmHg	Intraocular pressure mmHg
Fundoscopy - Any Abnormalities	Dilated Non dilated	Fundoscopy - Any Abnormalities (OD)	Fundoscopy - Any Abnormalities (OS)

Patient suitability

Why is the patient interested in refractive surgery?

Any particular comments as to the patient's suitability for surgery?

Patients

Optometrist bank details for Eftpos payment of fees

BSB

Account Number

Account Name