La Trobe University > School of Allied Health, Human Services and Sport > Clinics > La Trobe Eye Clinic > Maternal and Child Health referrals

Maternal and Child Health referrals

Please complete this form to refer an infant or child (0-5 years) for an orthoptic assessment at the La Trobe Eye Clinic.

The Clinic will contact the parent/guardian to make an appointment within seven days.

Details of infant or child being referred

Child's first name *

Child's surname *

Child's date of birth *

Day Month Year

Gestation *

Male
Female

Parent/guardian's first name *

Parent/guardian's surname *

Address * Street Address, Suburb, State and postcode

Contact number *

Additional contact number

Additional details

Date of assessment *

Day Month Year

Vision screening results (R) MIST result (if relevant/known)

Vision screening results (L) MIST result (if relevant/known)

Reason for referral *

Visual behaviour below expected age level
Abnormal head posture
Failed MIST vision screening test
Confirmed or suspected strabismus (squint/eye turn)
Family history of strabismus (squint/eye turn) or vision disorder
Parental concern regarding the child’s eyes/vision
Incomplete or unreliable assessment
Other (please specify below)

Additional comments Please add below any additional relevant information.

Referrer

Salutation

First name *

Surname *

MCH Municipality *

MCH Centre *

MCH Centre address *

Telephone number *

Email * 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/