Welcome to Macular Disease Foundation Australia Refer to us - Welcome to Macular Disease Foundation Australia

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*

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*

Postcode*

Please provide at least one contact number*:

Phone

Mobile

Does this person require an interpretor?:

YesNo

Please tell us which language*

If other, please state:*

Please indicate any topics you would like the MDFA education team to provide information on:

My EyesDisease informationRisk factorsAREDS2 supplementsSelf-monitoringAppointment adherenceGovernment supportMedicare and PBSPeer supportOther

If other, please state:

Comments:

To ensure we comply with Australia privacy laws, please do NOT include clinical information in the box below.

Newsletter signup

By postBy audio CDBy emailBy email (text only)

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.

Patient/client agrees

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

First name*

Last name*

Address*

Suburb*

State/Territory*

Postcode*

Please provide at least one contact number*:

Phone

Mobile

Does this person require an interpretor?:

YesNo

Please tell us which language*

If other, please state:*

Please indicate any topics you would like the MDFA education team to provide information on:

My EyesDisease informationRisk factorsAREDS2 supplementsSelf-monitoringAppointment adherenceGovernment supportMedicare and PBSPeer supportOther

If other, please state:

Comments:

To ensure we comply with Australia privacy laws, please do NOT include clinical information in the box below.

Newsletter signup

By postBy audio CDBy emailBy email (text only)

Refer to us

Refer my patient to MDFA

Refer myself to MDFA

Referrer’s details

Patient/client details

Patient/client details

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