Please fill out the referral form below to refer your patient/s
or you can download a
and email to
If your patient is required to see one of our ophthalmologists urgently (within 1-2 days), please call the clinic directly on (03) 9417 1011.
For after hours care, please direct the patient to the Royal Victorian Eye and Ear hospital (RVEEH).
Patients First Name
Patient's Last Name
Date of Birth
Phone (M) & (H)
Reason for Referral / Relevant History
Reason for Referral
Name / Provider number / Telephone / Address