Self Referral If you are experiencing significant difficulty with your sight, please complete this form and we will be in touch with you shortly. To help us direct your referral to the closest regional office please tell us which county you live in –None–CarlowCavanClareCorkDonegalDublinGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperary – NorthTipperary – SouthWaterfordWestmeathWexfordWicklow How did you hear about NCBI Services? –None–NCBI RetailWebNewspaperFamily/FriendAdvised by OphthalmologistAdvised by OpticianAdvised by Visiting TeacherOther Date of Referral: Please use the format dd/mm/yyyy: First Name (Required): Last Name (Required): Your date of birth – please use the format (dd/mm/yyyy): Email (Required): Phone: Mobile: Street: Area/Town: City/County: Post Code: Gender:–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: Further information:
