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Long Sightedness
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Posterior Capsule Opacity
Presbyopia
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Symptoms
Blurred Vision
Contact Lens Problems
Double Vision
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Laser Capsulotomy [YAG]
Macular Degeneration [AMD]
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Retinal vein occlusion
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Title*
Mr
Mrs
Ms
Miss
Problem/Complaint
Preferred clinic location
North Shore Clinic
Remuera Clinic
Manukau Clinic
New Lynn Clinic
Referred to*
1st available
Dr William Cunningham
Prof Helen Danesh-Meyer
Dr Simon Dean
Dr Trevor Gray
Dr Peter Hadden
Dr Nick Mantell
Prof Charles McGhee
Dr Jay Meyer
Dr Graham Reeves
Dr Peter Ring
Dr Shanu Subbiah
Dr Adam Watson
Thank you for seeing my patient for assessment of
Cataract
Cornea
Uveitis
Neuro-ophth’
Glaucoma
Ocular surface
Lids/lacrimal
Dry eye unit
Retina
Refractive surgery
Oculoplastics
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Comments
Appointment made?
No, Eye Institute to contact patient
Yes, for date
Referred by
You will be emailed a copy of this referral for your patients records.
Note: None of this information will be passed on to any other party. *Denotes mandatory fields.
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