Online Referral

If you are a GP or Optometrist, you can refer a patient by completing the form below or by contacting us directly at info@eyeslidsandface.ie.

Patient Name

First Name

Last Name

Date of Birth

YYYY

Patient's Email Address

Patient's Contact Number

(###)

###

####

The above patient is being referred for:

(Kindly note that we do not provide emergency services yet for new patients. )

General Ophthalmology

Glaucoma

Cataract Assessment

Medical Retina

Full eye examination for another cause not listed above

Subject

Please include any additional relevant information to support the referral:

Referral submitted by:

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referrer's email address / healthmail

A confirmation of your referral submission will be sent to you by email.