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Practitioner Referral

Pre-Operative Refractive Report

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Patient information
Patients health
Examination information
Labels Right (OD) Left (OS)
Current spectacle refraction
Add - if applicable
If wearing contacts state type
Is refraction stable?
Current refraction
(incl. BVD if >6 dioptres)
Visual acuity with current refraction 6 / 6 /
Keratometry (dioptres, axis)
Slit lamp exam
Any Abnormalities
Intraocular pressure mmHg mmHg
Fundoscopy -
Any Abnormalities
Patient suitability

Optometrist bank details for Eftpos payment of fees