ROYAL HOBART HOSPITAL
LIONS LOW VISION CLINIC
GPO Box 1061 Hobart TAS 7001
 
Ph (03) 6222 8310   Fax (03) 6222 6662
email: llvc@dhhs.tas.gov.au 	

Referral to Andrew Maver, Paul Graveson, Rebecca Burrows

		    Appointment needed: 	q	Urgent	q	Standard

 Patient Details	 Name:  <PtName>	
	 Address:  <PtAddress> 	
	 DOB:  <PtDoB>		Medicare: <PtMCNo>	
	 (h) <PtPhoneH> 	 (w) <PtPhoneWk>	(m) <PtPhoneMob>	

 Eye Condition(s)	

	
 Refraction	 Right 		6/		Left			6/	
		
 Difficulties 	  q	Reading		q	Television		q	Getting Around	
	  q	Computer		q	Art/Craft		q	Glare	
	  q	Medications		q	Cooking		q	Faces	
	  q	Other..

 Special Requests	 q	In-home visit (lighting,activities of daily living, home safety)	
	 q	Orientation and mobility assessment	
	 q	Assistance with pensions/support services/bus passes etc	
	 q	Other..

 Referred By	 Name: <DrName>		Prov: <DrProviderNo> 	
	 Address: <DrAddress>  	
	 (p) <DrPhone>  (f) <DrFax>  (e) <DrEmail>	

Signed: 						Date: <TodaysDate>	

For an appointment please phone 6222 8310 or email llvc@dhhs.tas.gov.au
then post or fax this referral. Copies of this form can be downloaded from
www.dhhs.tas.gov.au/services (search “Low Vision Clinic” )