Is this an initial or review referral?
(circle the appropriate)
| Surname Given name |
| Date of Birth |
| Address |
| HomeTelephone |
| School/Kinder Year level |
| Address |
| Contact Person Principal |
| Telephone |
| Referred by |
| Address |
| Telephone |
Ophthalmologist:_________________________________________________________________
(If ophthalmologist has not been seen in the last six months, this should be arranged prior to referral)
If seen in hospital, private or public patient? __________________________________________
UR Number, if available ___________________________________________________________
Address __________________________________________________________________________
Telephone _______________________________________________________________________
Paediatrician ____________________________________________________________________
Address _________________________________________________________________________
Other agencies involved (eg. RVIB) _________________________________________________
Reason for Referral_______________________________________________________________
_________________________________________________________________________________
Is an Interpreter required?_________________Language required_______________________
PERMISSION FOR MEDICAL REPORT
I, . Give permission to the EVAC team to obtain a medical report
regarding (name of student) ..
from (name and address of doctor/s) .
Signed . Date .......
(parent/guardian)
Please return this completed form to:
ATTENTION: Annette Godfrey-Magee/Marion Blazé
Educational Vision Assessment Clinic (EVAC)
Education Officer for Vision Impairment
PO Box 201
NUNAWADING 3131
PH: (03) 9841 0807 FAX: (03) 9841 0878