Ophthalmic Referral Form

Make an Ophthalmic Referral

To make an ophthalmic referral please tell us about your patient by completing the form below. There is the option to attach documents such as a clinic letter or visual field results at the end of the form

Is your patient's eye condition the result of an accident?

YesNo

Important note: We can still proceed with your referral, however, will need more information from your patient. For example, Blind Low Vision NZ will need to be notified of the date of the accident, type of injury and if possible of their ACC claim number if already known. The person you are referring additionally needs to be referred to ACC in order to make a claim.

Date of Accident

Type of injury

ACC Claim Number

What are your patient's details?

Please type in your patient's personal details as they appear on official documents. This helps us to prevent the creation of duplicate records in case they were already registered with us.

Personal Details

Title

First Name

Middle Name

Last Name

Known as

Date of Birth

NHI Number

Gender

Ethnicity

If you cannot find a certain ethnicity in the picklist, then please select "Other".

Contact Details

What is their call preference?

Home Phone

Mobile Phone

Work Phone

Street Address

Suburb

City

Postal Code

What are your details?

Eye Clinic / Practice

First Name

Last Name

Position

What is your call preference?

Work Phone

Mobile Phone

Home Phone

Street Address

Suburb

City

Postal Code

Ophthalmic Details

To complete your referral, we need to know a bit more about your patient's eye health including:

Their best corrected visual acuity in each eye
Visual field for each eye if appropriate
Your diagnosis for each eye
Their prognosis
Any additional info you would like to mention

You can choose either:

Enter Ophthalmic DetailsAttach Ophthalmic Letter

Best corrected visual acuity

Distance Vision

Right Eye

Left Eye

Binocular

If other please specify

Near Vision

Please specify for both eyes

Field of Vision

Right Eye

Left Eye

If other please specify

Diagnosis

Please specify your patient's diagnosis for each eye. You can select common eye conditions in the picklists below. If you cannot find the eye condition of your patient, please select "Other disorders of the eye" and specify in the provided text field.

Primary Diagnosis

Right Eye

Left Eye

Secondary Diagnosis

Right Eye

Left Eye

Additional diagnosis or information

Additional Information

Prognosis

Additional Prognosis Information

Date of last eye examination

Does the patient have diabetes?

YesNo

Does your patient have functional hearing difficulties?

YesNo

Other health conditions / additional comments

Before you submit your referral...

Attach any supporting documentation using the button below:

Attach Files

Is your patient aware of this referral?

YesNo

Important note: We can still proceed with your referral, however, could you please provide the reason why this request has not been discussed with your patient? Please note, we will be contacting the person being referred to obtain additional information and confirm their request for service.

Why has your referral not been discussed?

Rights & Privacy

Blind Low Vision NZ is governed by the Health and Disability Code of Rights. Click here to find out about the rights under the Code.
Blind Low Vision NZ is committed to protecting the privacy of our clients and works in accordance with the Privacy Act 2020. Click here to find out about the Privacy Act 2020.
Blind Low Vision NZ will keep information about you and the person your are referring confidential, as outlined in our privacy statement. Click here to open our privacy statement.