Visual Electrophysiology Referral

SAVE SIGHT INSTITUTE
South Block, Sydney Eye Hospital 8 Macquarie Street, SYDNEY NSW 2000

Tel: (02) 9382 7300

Email: ssi.clinic@sydney.edu.au

www.sydney.edu.au/save-sight-institute/
SAVE SIGHT INSTITUTE VISUAL ELECTROPHYSIOLOGY INVESTIGATIONS REFERRAL
PATIENT DETAILS
Name*
Date of Birth*

DayMonthYear
Date
Address*
Phone Number*
This is a referral for visual electrophysiology investigation with a provisional diagnosis of:
RETINAL

Suspected generalised retinal disorderMacular dysfunctionBests or Adult VitelliformBirdshot chorioretinitisHydroxychloroquine (Plaquenil) screening
OTHER/NEURO

Unexplained vision or visual field lossOptic neuropathyAlbinismNystagmus for investigationOther
Affected Eye

RightLeftBoth
Visual Acuity

correcteduncorrected
RE
LE
BEO
Other relevant information (e.g. language, hearing/mobility difficulties)
Additional documents attached

NilVisual FieldsMRIOther
List of eye drops patient might be using
Please confirm that there are NO contraindications for dilation by initialling here*
REFERING PRACTITIONER DETAILS
Full Name*
Provider Number*
Clinic Location*
Contact Number*
Please be aware that without adequate information the patient's testing may be delayed.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

SAVE SIGHT INSTITUTE