FAST TRACK CATARACT REFERRAL FORM

This form facilitates fast track referral of patients for cataract surgery, either in a public or private hospital. Fields are provided for public/ private surgery preferences and refractive outcome. These are optional.
For convenience, note that apart from your referrer details, there are only three other mandatory fields: the patient's name, phone number and side of cataract (right or left). The remaining fields are optional and can be left blank. Click on the UPLOAD FILE box below to forward clinical photos, scans and results. Thank you for your referral and we look forward to any feedback you may wish to send us, via our ASK A QUESTION FORM
Note: This Referral Form uses SSL security protocol for encryption of data transmission

    Patient details (only name and phone number are required):

    Referral details (required):

    Referrer's details (required):
    THIS SECTION BELOW RELATES TO THE PATIENT'S REFRACTIVE DETAILS AND COMORBIDITIES AND CAN BE LEFT BLANK (scroll down and click the SUBMIT button)
    PREOP REFRACTION (Optional) select drop down options or enter manually below:
    POSTOP REFRACTION (optional)
    FILE UPLOAD
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
    Max file size: 20MB
Lifestyle Vision Questionnaire (Optional)
The questionnaire below can be printed and given to your patient for completion. Submitting the completed form will help us decide the best postoperative refractive state to match your patient's eye condition, lifestyle and aspirations, where possible.