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
VISUAL ELECTROPHYSIOLOGY INVESTIGATIONS REFERRAL
PATIENT DETAILS
Name
*
Date of Birth
*
/
Day
/
Month
Year
Date
Address
*
Phone Number
-
Area Code
Phone Number
Phone Number
*
This is a referral for visual electrophysiology investigation with a provisional diagnosis of:
RETINAL
Suspected generalised retinal disorder
Macular dysfunction
Bests or Adult Vitelliform
Birdshot chorioretinitis
Hydroxychloroquine (Plaquenil) screening
OTHER/NEURO
Unexplained vision or visual field loss
Optic neuropathy
Albinism
Nystagmus for investigation
Other
Affected Eye
Right
Left
Both
Visual Acuity
corrected
uncorrected
RE
LE
BEO
Other relevant information (e.g. language, hearing/mobility difficulties)
Additional documents attached
Nil
Visual Fields
MRI
Other
Upload Clinical Letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
*
/
Day
/
Month
Year
Date
Preview PDF
Submit
Should be Empty: