Macular Disease Foundation Australia logo

Refer a patient

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:


    Newsletter signup