Internal Use Only

Dubbo Public Eye Clinic
Dubbo Health Service – Ambulatory Care Centre
 170 Myall St, Dubbo, NSW 2830
 Phone: 02 6809 6000 for ALL general enquiries                            We accept referrals by email or Argus only;
Referrals ONLY to: wnswlhd-DPECReferrals@health.nsw.gov.au or Argus wnswlhd-ccdubsmc@health.nsw.gov.au
If the appointment is urgent please state it in the ‘subject’ of the email.	
Referral to: 
Dr Chris Qureshi 	Referral to: 
Dr Jeremy Curtin	Referral Date:  <<Miscellaneous:Date>>	
Patient Details: <<Patient Demographics:Title>>	
Surname:	<<Patient Demographics:Surname>>
	Given Name/s:	<<Patient Demographics:Full Name>>	
Date of Birth: 	
 <<Patient Demographics:DOB>>         	
<<Patient Demographics:Gender>>	

Email:	
<<Patient Demographics:E-mail>>	

	Medicare number:	<<Patient Demographics:Medicare Number>>	

Ref: 	
Exp:   <<Patient Demographics:Medicare Expiry Date>>      	

Contact Number/s:
	<<Patient Demographics:Phone (Mobile)>>	Interpreter Required?	Yes/No
Language:	
Indigenous Status:	<<Indigenous Status>>	
Postal Address:	<<Patient Demographics:Full Address Postal>>	
Next Of Kin:	
<<Patient Demographics:Next of Kin>>	

Relationship:	
<<Patient Demographics:Next of Kin Relationship>>	

	Contact Number/s of N.O.K:	<<Patient Demographics:Next of Kin Phone>>	
				
 Please note: Incomplete referrals will not be triaged. We strongly encourage a full optometry review prior to referral.	
Clinical Reason for Referral: <<Clinical Reason for Referral>>	
Relevant Ocular/Medical History:

Previous Ophthalmic: <<Previous Ophthalmic>>	Relevant Eye Drops and Medications:	
Driving:
Yes/No	Visual Acuity	

Unaided	
BC (glasses/ PH)	

	IOP
(mm Hg)	Refraction	

Sphere	
Cyl	
Axis	
Prism	
Base	
Add	

Right Eye:	6/	6/								
Left Eye:	6/	6/								
Investigations: (OCT/ VF/ Biometry/ FFA/ ERG/ Radiology/ Pathology/ Tomography/ Other)

				
Referring Practitioner: <<Referring Practitioner>>	
Name:	<<Doctor:Name>>	Provider No:	<<Doctor:Provider Number>>
	
Practice Address:	<<Practice/Location:Address>>	
						
Western NSW Local Health District is committed to integrated care. Please gain the patient’s verbal consent and provide the details below of other health professionals involved in their care (for future clinical correspondence).	
General Practitioner:
Address:

Phone:	Optometrist:

Address:

Phone:
	Ophthalmologist:

Address:

Phone: