Refer a patient

Posted By admin On 21/09/2020 @ 4:04 pm

This referral form is for professional use by registered health practitioners or other organisations providing support to individuals with macular disease. You need consent from the person to refer to us.

If you don’t have easy access to all the information required in the form below, please contact MDFA’s National Helpline on 1800 111 709 or via email. We’d love to hear from you.

Referrer’s details

Please tell us a little about you as the person providing the referral. This helps us when we connect with your patient or client.

Referring person’s first name

Referring person’s surname

Referring person’s organisation

Organisation town/suburb

Referring person's email

Referrer type

If other, please state:

Macula Matters

I would like to receive Macula Matters, a free quarterly e-newsletter for eye health professionals.

Email address

Patient/client details

Please ask your patient/client to agree to this statement:

I agree for this practice to provide my personal information (name, contact details, information about my eye health) to Macular Disease Foundation Australia so that MDFA can contact me with information about macular disease and MDFA’s services.

Patient/client agrees

Date on which the patient agreed to share their details with MDFA*:

First name

Last name

Address

Suburb

State/Territory