Maternal Child and Health Referrals

Please complete the below form to refer an infant or child (0-5 years) for an orthoptic assessment at the La Trobe Orthoptic Eye Clinic. The clinic will contact the parent/guardian to make an appointment within 7 days.


Details of infant or child being referred
Childs Date of Birth *
Gestation *
Street Address, Suburb, State and postcode
Additional details
Date of Assessment *
MIST result (if relevant/known)
MIST result (if relevant/known)
Reason for Referral *
Please add below any additional relevant information.
Referrer
Please ensure the email below is correct. A confirmation email will be sent to this address.
Validation

 

Confidentiality

All information provided will be treated as confidential. At La Trobe University, we respect the privacy of your personal information. We collect personal information in your application in order to handle your enquiry. A copy of your submission will be sent to your referrer. In accordance with privacy laws, personal information about you contained in your enquiry will not be used for any other purpose. You may have the right to access personal information we hold about you, subject to any exceptions in relevant laws, by contacting the Eye Clinic via email at eye.clinic@latrobe.edu.au The La Trobe University privacy policy can be viewed at: www.latrobe.edu.au/privacy/