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(02) 9874 5947
22 East Parade, Eastwood NSW 2122
Mon to Fri, 8:30am to 5:00pm
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About Us
Dr Gagan Khannah
Dr Rajiv Shah
Dr Dov Hersh
Dr Andrew Kaines
Dr Mark Gorbatov
Eastwood Rooms
Eye Conditions
Cataracts
Glaucoma
Age-Related Macular Degeneration (AMD)
Diabetic Eye Disease
Retinal Conditions
Floaters and Flashes
Cornea and Ocular Surface
Eyelid Conditions
Treatments
Cataract Surgery
Advanced Laser Treatments
Intravitreal Injections
Retinal Surgery
Eyelid Procedures
Pterygium Surgery
Patient Info
Patient Information
New Patients
Patient Registration
Frequently Asked Questions (FAQs)
Eye Health Resources
Eye Health Resources
What to Expect from Cataract Surgery
Floaters and Flashes Explained
Diabetes and Your Eyes
Referrals
Referral Information
Patient Referral Form
Request an appointment
Patient info
Patient Referral Form
Optometrists and GPs Referrer Form
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PATIENT DETAILS
Name
*
Date of Birth
*
Contact Phone
*
Language Preference (If Applicable)
English
Mandarin
Cantonese
Korean
Other
Other Language
CLINICAL DATA
Visual Acuity and Refraction
Right Eye
RE With Glasses
Yes
No
Left Eye
LE With Glasses
Yes
No
Lifestyle and Glare Impact
Night Driving
Reading
Computer Intermediate work
Sports
Other
Diagnostic Data Attached
Auto-Refractor
Corneal Topography
OCT Scan
None
Other Lifestyle
Please tick Patient interests / Surgical goals
Premium IOL / Reduced Spectacle Dependence (Trifocal / EDOF / Toric)
Monovision / Blended Vision Strategy
Standard Monofocal (Distance or near) with Post-Op Spectacles
General Cataract Assessment / Medical Necessity
REFERRING OPTOMETRIST
Name
*
Practice Name
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Provider Number
Phone Number
Email Address
Signature
Date
