Referral

At Laser Eye Centre we believe by working together, our patients receive first class treatments and ongoing vision care—the kind of care that ensures quality vision and positive surgical results.

One important aspect of our Shared-Care with you, is prompt and detailed communication.

Clinical Referral

Patient Name*

Date of birth

Phone number

Address

Postcode*

Problem/ Complaint

Preferred clinic location

Referred to*

Comments

Refractions

(R)6/

(R) Add+ N

(L)6/

(L) Add+ N

Appointment made?

No, Laser Eye Centre to contact patient Yes, for below date

Date

Referred by

Optometrist Name*

Name of practice

Referral date

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