Referral Letter (Ophthalmology/Medical Specialist)

Date: [Date of referral]

To: [Specialist name, credentials, specialty, clinic/address]

From: [Referring clinician name, credentials, specialty, practice, contact info]

Patient: [Full name, DOB, sex/gender, contact number if relevant]

Subject: [One-line reason for referral including laterality if eye-related and requested urgency/timeframe]

Attachments: [List attached reports/images/test results with dates]

Reason for Referral

(Keep this section scannable—3–5 bullets maximum. Clearly state the problem, urgency, and consult request.)

• [Primary concern with time course and laterality] (Use OD/OS/OU; define at first use if recipient outside ophthalmology.)
• [Key objective findings or test results justifying referral]
• [Working diagnosis or leading concern] (State uncertainty explicitly if present.)
• [Urgency and requested timeframe with brief rationale]
• [Specific question or action requested from specialist]

Clinical Background

History of Present Illness: [Concise narrative of onset, progression, and pertinent positives/negatives relevant to the referral]

Pertinent Ocular History: [Prior diagnoses, surgeries, baseline VA if known, relevant risk factors—include laterality]

Pertinent Medical History: [Relevant systemic conditions] (E.g., diabetes, autoimmune disease, anticoagulation, immunosuppression, operative risk factors.)

Medications: [Ocular medications with laterality and dose/frequency, then relevant systemic medications] (Note if reconciliation incomplete and source of information.)

Allergies: [Allergen(s) and reaction type] (If none, state "NKDA"; if unknown, state "Allergies: unknown"—do not leave blank.)

Objective Findings

Exam date/time: [Date and time] (Note limitations such as telemedicine, equipment unavailable, dilation declined.)

Key ophthalmic findings: [VA with correction status, IOP with method, and other pertinent exam findings by structure—use OD/OS/OU throughout] (For any critical datum not obtained, state "not assessed" with reason.)

Testing: [Relevant test results with dates, key values, and brief interpretation—attach full reports/images when available]

Assessment

[Working diagnosis with laterality and severity/stage if known] (If diagnostically uncertain, include 2–4 differential considerations with brief supporting rationale.)

Red flags present: [List only if present—rapid vision loss, severe pain, disc edema, markedly elevated IOP, neurologic deficits, immunocompromise]

Request

Consult question(s): [Specific diagnostic, treatment, surgical, or co-management question(s) for the specialist]

Urgency/timeframe: [Requested timeline and rationale]

Scope: [One-time consult / Procedure evaluation / Transfer of care / Shared management—define responsibilities if shared]

Urgent contact: [If urgent, document clinician-to-clinician contact attempt and outcome] (Include only for urgent referrals.)

Callback/reply: [Direct phone for urgent findings] | [Preferred reply method]

Sincerely,

[Referring clinician name, credentials]
[Role/Title]
[Practice/Organization]
[Direct phone] | [Secure email/fax]