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Refer to us

You can refer yourself or have your healthcare provider refer to us via this e-referral form.

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 on info@mdfoundation.com.au.

    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.






    Referrer type


    Macula Matters


    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.

    First name

    Last name

    Address

    Suburb

    State/Territory

    Postcode

    Email

    Please provide at least one contact number*:

    Phone

    Mobile

    Does this person require an interpretor?:

    Please tell us which language

    If other, please state:


    Comments:


    Newsletter signup

      Patient/client details

      Please read and agree to the below statement:

      I agree 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.

      First name

      Last name

      Address

      Suburb

      State/Territory

      Postcode

      Email

      Please provide at least one contact number*:

      Phone

      Mobile

      Does this person require an interpretor?:

      Please tell us which language

      If other, please state:


      Comments:


      Newsletter signup