RELATIVE OR FRIEND REFERRAL If you know someone experiencing significant difficulty with their sight, please complete this form and we will be in touch with them shortly. 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 How did you hear about NCBI Services? –None–NCBI RetailWebNewspaperFamily/FriendAdvised by OphthalmologistAdvised by OpticianAdvised by Visiting TeacherOther Your Name (required): Relationship to person you are referring:–None–MotherFatherSonDaughterSpouse/PartnerGuardianFriend Date of Referral: Please use the format dd/mm/yyyy: First Name of relative/friend (required): Last Name of relative/friend (required): Relative /friend’s Email : Relative /friend’s Phone: (Required) Relative /friend’s Mobile: Street of Relative /friend: Area/Town of Relative /friend: City/County of Relative /friend: Post Code of Relative /friend: Relative / friend’s date of birth – please use the format (dd/mm/yyyy): Is your relative / friend male or female?:–None–MaleFemale Ophthalmic Diagnosis: (if known)–None–AlbinismARMDCataractsCongenital NystagmusDiabetic RetinopathyGlaucomaNVI/CVIOptic Nerve HypoplasiaRetinal DetachmentRetinal DystrophyRetinal Pigmentosa (RP)StargardtsOther (specify text box)Unknown Ophthalmic Diagnosis (Other): Reason for Referral: Is the person aware of the referral:–None–YesNo Can Direct Contact be made with Person:–None–YesNo Reason Direct Contact cannot be made: Further information:
