Request Appointment

Urgent Requests

During business hours:
- Please contact us directly to arrange urgent treatment with an appropriate Ophthalmologist.
After business hours, weekends & public holidays:
- Post-operative patients of practices working out of Eye Surgery Associates premises – please contact your surgeon with the emergency number provided to you.
- Please contact the Royal Victorian Eye & Ear Hospital at 32 Gisborne Street, East Melbourne on 03 9929 8666 or call 000 in an Emergency.

For all other/general appointment requests, please complete the form below.

Name*
First Surname (Family Name)
Date of Birth
DD slash MM slash YYYY

If an existing patient, DOB assists in identifying you in our system.
Phone number*
Email*
Address
Address Line 1 Address Line 2 Suburb State Post Code Country
Name of Eye Specialist at ESA you wish to see
Preferred Appointment Location
- East Melbourne
- Malvern
- Doncaster
- Vermont South
- Wherever the Specialist consults
Please note: Specialists are not available at all sites.
Your referring Doctor/ Optometrist / Specialist Details
Referrer's Name Referrer's Address Referrer's Phone Number Referrer's Email
Condition
Reason for Appointment*
Please provide information about the reason you've been referred to us so that our staff can assist you with your appointment (250 max characters).
Upload Referral Letter:
Drop files here or

Max. file size: 2 GB.
Please upload a referral letter here (where applicable)
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Eye Surgery Associates