Professional Referral To help us direct your referral to the closest regional office please tell us which county the person you are referring lives in –None–CarlowCavanClareCorkDonegalDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperary – NorthTipperary – SouthWaterfordWestmeathWexfordWicklow Date of Referral: Please use the format dd/mm/yyyy: Patient’s First Name (Required): Patient’s Last Name (Required): Patient’s Phone: Patient’s Mobile: Patient’s Street: Patient’s Area/Town: Patient’s City/County: Patient’s Post Code: Patient’s Gender:–None–MaleFemale Patient’s Date of Birth: Please use the format dd/mm/yyyy: Ophthalmic Diagnosis: (if known)–None–AlbinismARMDCataractsCongenital NystagmusDiabetic RetinopathyGlaucomaNVI/CVIOptic Nerve HypoplasiaRetinal DetachmentRetinal DystrophyRetinal Pigmentosa (RP)StargardtsOther (specify text box)Unknown Ophthalmic Diagnosis (Other): Maximum Characters Allowed 500 Right Eye (Acuity): Left Eye (Acuity): Right Eye (Refraction): Left Eye (Refraction): Right Eye (Field Loss): Left Eye (Field Loss): Reason for Referral: (Maximum Characters Allowed 500)Is Person Aware of Referral:–None–YesNo Can Direct Contact be made with Person:–None–YesNo Reason Direct Contact cannot be made: (Maximum Characters Allowed 255) Alternative Contact Name: Alternative Contact Phone: Alternative Contact Address: Alternative Contact Relationship: Name of Professional Referring: Profession:–None–Age ActionGeneral PractitionerOccupational TherapistOphthalmologist – community basedOphthalmologist – hospital basedOptometristOrthoptistPhysiotherapistPublic Health NurseSocial WorkerStaff NurseVisiting TeacherOther Professional’s Organisation/Company name: Professional’s Organisation/Company Street: Professional Org Street: Professional Org Area/Town: Professional Org City/County: Professional Org Eircode: Professional Landline: Professional Mobile: Professional email: Professional Organisation Type:–None–HospitalPrivate PracticeClinicPrimary Care CentreMedical CentreHealth Centre
