Internal Use Only

Ophthalmology Referral - Prince of Wales Outback Eye Service
Bourke Health Service fax: 6870 2680, Brewarrina Health Service fax: 6839 2822, 
Cobar Health Service fax: 6879 9580,
Lightning Ridge Health Service fax: 6820 5780, Walgett Health Service fax: 6817 9480
Phone: 0418 322 705 (Joanna) 0419 111 687 (Ben) for all general enquiries
We accept referrals by fax to your preferred clinic location or email: WNSWLHD-OESReferrals@health.nsw.gov.au If the appointment is urgent please phone Joanna/Ben for next clinic availability.

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: