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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 [email protected].

Patient/Client Details

Please enter your name.
Please enter your phone.
Please select a Macular Disease Type.

Referrer’s Details

Please enter your referrer First Name.
Please enter your referrer Last Name.
Please enter your referrer Email.
Please enter your referrer Organisation.
Please enter your Organisation Postcode.
Please enter your Date of Patient Consent.

Patient/Client Details


Please enter your name.
Please enter your phone.
Please select a Macular Disease Type.

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.

Please enter Date of Patient Consent.