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Macular Disease Foundation Australia logo

    Refer a patient

    MDFA provides free information, guidance and support to people living with macular disease. For privacy compliance, it's important patients understand that you'll be sharing their personal details.

    Man looking at letters on an eye chart

    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.






      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:


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