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

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].

Refer my patient to MDFA
Refer myself to MDFA

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

Referring person’s email

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