Table 2.

Referral letter template for glaucoma

Patient details	1. Name
	2. Date of birth
Patient systemic details	3. Medical illness
	4. Allergies
Ophthalmic details			Right eye	Left eye
	5. Visual acuity
	6. IOP (by )	Maximum/pretreatment
		Recent
	7. Angle status - Open or occludable
	8. Disc details - past and recent
	9. Field changes - past and recent
	10. Antiglaucoma medication - Number and duration
	11. Surgery - glaucoma/other
	12. Condition associated with glaucoma -Pseudoexfoliation or Pigment dispersion
	13. Other ocular pathology
Ophthalmic diagnosis	14. Diagnosis
	15. Duration of glaucoma
	16. Reason for referral
Referral doctor details	17. Name, address, contact number and e-mail id