Internal Use Only	
Dubbo Public Eye Clinic
Dubbo Health Service – Ambulatory Care Centre
 170 Myall St, Dubbo, NSW 2830
 Phone: 02 6809 6000  for ALL general enquiries                            We accept referrals by email or Argus only;
Referrals ONLY to: wnswlhd-DPECReferrals@health.nsw.gov.au or ARGUS: wnswlhd-ccdubsmc@health.nsw.gov.au
If the appointment is URGENT please state it in the ‘subject’ of the email.
Referral to: 
Dr Chris Qureshi	Referral to: 
Dr Jeremy Curtin	Referral Date: <<Miscellaneous:Date>>        	
Patient Details: <<Patient Demographics:Title>>	
Surname:	<<Patient Demographics:Surname>>	Given
Name/s:	<<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
Date of Birth:	<<Patient Demographics:DOB>>	Gender:	<<Patient Demographics:Gender>>	
Contact Numbers	Ph: <<Patient Demographics:Phone (Home)>>
Mob: <<Patient Demographics:Phone (Mobile)>>	Medicare No: 	<<Patient Demographics:Medicare Number>>          Exp: <<Patient Demographics:Medicare Expiry Date>>	
Indigenous Status: 	<<Patient Demographics:Ethnicity>>	Interpreter Required?	<<Interpreter Required?>>

Language: <<Patient Demographics:Language Preferred>>, Spoken: <<Patient Demographics:Language Spoken>>	
Postal Address	<<Patient Demographics:Full Address>>
	
Next of Kin:	<<Next of Kin name?>>	Contact Number/s of N.O.K	Ph:<<Next of kin phone number>>	
Relationship:	<<Next of Kin relationship>>		Mob: <<Next of kin mobile?>>	

Please note: Incomplete referrals will not be triaged. We strongly encourage a full optometry review prior to referral.	
Clinical Reason for Referral:
<<Reason for referral?>>	
Relevant Ocular/Medical History:
<<Relevant Ocular History>>
<<Clinical Details:History List>>

Previous Ophthalmic: <<Previous Ophthalmic>>	Relevant Eye Drops and Medications:
<<Relevant eye drops?>>

<<Clinical Details:Medication List>>	
Please enter in details below if known:
Driving:
	Visual Acuity	IOP	Refraction	
<<Driving?>>	Unaided	BC (glasses/PH)	(mm Hg)	Sphere	Cyl	Axis	Prism	Base	Add	
Right Eye	6/	6/								
Left Eye	6/	6/								

Referring Practitioner:<<Referring Practitioner?>>	
Name:	<<Doctor:Name>>	Provider Number	<<Doctor:Provider Number>>	
Practice 
Address:	<<Practice:Address>>                                         Phone: <<Practice:Phone>>	

Western NSW Local Health District is committed to integrated care. Please gain the patient’s verbal consent and provide the details below of other health professionals involved in their care (for future clinical correspondence).	
Optometrist: <<Optometrist Name?>>
Adresss: <<Optometrist Address?>>
Phone: <<Optometrist Phone?>>	Ophthalmologist: <<Ophthalmologist Name?>> 
Address: <<Ophthalmologist address?>>
Phone: <<Ophthalmologist Phone?>>	
Ophthalmology Referral Options
Refer to Emergency Department	Refer to Dubbo Public Eye Clinic	
Emergency
Urgent cases need to be seen immediately	Category 1
Urgent next clinic	Category 2
< 3 months	Category 3
< 6 months	
•	Acute angle closure glaucoma
•	Acute vision loss or signs of stroke
•	Central retinal artery occlusion 
•	Chemical injury
•	Giant Cell Arteritis  
•	Infectious keratitis (Hypopyon, fungal, Gonococcal/Chlamydia  
•	Intraocular foreign bodies 
•	Malignant hypertension
•	Orbital cellulitis/acute dacryocystitis
•	Orbital fractures 
•	Retinal detachment (macula on, if macula off can wait up to a week) 
•	Superior retinal tear 
•	Suspecting penetrating eye injury 
•	Transient Ischemic Attack/Amaurosis fugax 
	•	Acquired nystagmus 
•	Acute visual field loss
•	 Choroidal Melanoma or suspected retinal tumours
•	Corneal decompensation (Bullous Keratopathy, Endothelial Keratopathy) 
•	Cranial nerve palsies 
•	Diabetes with sudden vision loss
•	Ischemic ocular conditions 
•	Macula hole
•	Macula oedema 
•	Non-resolving Central Serous Chorioretinopathy 
•	Optic neuritis 
•	Papilledema 
•	Post-op injection inflammation 
•	Proliferative diabetic retinopathy
•	Proptosis with visual changes 
•	Ptosis if pupil occluded
•	Recent onset pupil changes
•	Retinal tear (not superior) 
•	Retinopathy of prematurity
•	Vitreous haemorrhage with retinal pathology (excluding Posterior Vitriol Detachment)
•	Wet Age Related Macular Degeneration  
•	White pupil reflex in children 	•	Cataract with Best Corrected Visual Acuity (BCVA)  > 6/21 
•	Epiretinal membrane with vitreoretinal traction VA >6/12
•	Eyelid tumours 
•	Glaucoma un-responsive to topical therapy 
•	Recent onset retinal hole 
•	Severe non-proliferative diabetic retinopathy without macula oedema 	•	Cataract with Best Corrected Visual Acuity (BCVA) >6/12  <6/21
•	Epiretinal membrane symptomatic 
•	Eyelid problems: ectropion/entropion/ptosis
•	Proptosis without visual issues (Thyroid eye disease) 
•	Pterygium encroaching pupil margin 
•	Retinoschisis 
•	Retinoschisis requiring treatment 
•	Unresolving large chalazion 
	
Refer to local Optometrist	
Category 4	
•	Cataract with Best Corrected Visual Acuity BCVA  <6/12 
•	Chemical injury follow up
•	Choroidal naevus 
•	Congenital nystagmus 
•	Conjunctivitis
•	Contact lens complications 
•	Corneal and sub-tarsal foreign bodies
•	Corneal ulceration
•	Diabetes review, non-proliferative diabetic retinopathy (mild-mod)	•	Drug toxicity screening ie. Plaquenil/tamoxifen 
•	Dry Age Related Macular Degeneration
•	Elevated intraocular pressure >30mmHg 
•	Epiretinal membrane asymptomatic and no significant distortion 
•	Eye discharge 
•	Eye health screening
•	Eye pain 
•	Eyelid lumps (stye, chalazion)  	•	Flashes, floaters  
•	Fuchs dystrophy 
•	Glaucoma suspect
•	Herpes simplex/ zoster infection
•	Hyphema 
•	Keratoconus 
•	Monitoring of long-standing retinal hole and retinoschisis 
•	Non-infectious Keratitis 
•	Post-op cataract inflammation	•	Pterygium visually insignificant 
•	Pupil changes with change in vision 
•	Refractive error, presbyopia 
•	Severe dry eyes, watery eyes, blepharitis
•	Strabismus, amblyopia 
•	Sudden onset of blurred vision/ headaches/diplopia
•	Swollen eye
•	Trauma to eye/orbit, chemical burns 
•	Uveitis