Download Ophthalmology Referral Form

Ophthalmology Referral Form
Referral should be made by FAX to the Patient Care Advisors
Central Lancashire Patient Care Advisors
Clinical Speciality: Assessment for Cataract Surgery
FAX: 01772 769634
DOB
Female
Title:
First Name:
Patient Surname:
Previous Surname:
Patient Address:
Male
NHS No (if known):
Post Code:
Tel.(Daytime):
Tel.(Evening):
Mobile
e-mail address (if known)
Temporary Resident:
Yes
No
Overseas Visitor:
Yes
No
Yes
No
Language Spoken:
Interpreter Required:
Special Requirements:
Referring Optometrist (PLEASE USE BLOCK CAPITALS)
Council Registration Number:
Name:
Address:
Registered GP Practice (if different)
Name:
Address:
Post Code:
TEL:
Post Code:
TEL:
FAX:
FAX:
Please confirm the patient:
Has  A visually significant cataract
Has Any
 Known Diabetic retinopathy
 Significant age-related Macular Degeneration
 Other significant ocular pathology
 Other retinal vascular disorders
 Corneal Pathology
 Glaucoma
 Amblyopia
ANY ADDITIONAL INFORMATION
Cataract (please circle) : Right / Left / Both eyes
Patient’s visual status
Current BEST corrected VA
Current Refraction
Previous VA if known
Previous refraction if known
Intra Ocular Pressure
Right eye
6/
Left Eye
6/
6/
6/
…………mmHg
……….mmHg
What symptoms is the patient having:




Gradual reduction in vision
Difficulty in activities of daily living
Glare
Monocular diplopia
Date Where Appropriate
Method of recording IOP
NCT/Goldman/Perkins/OBF
Has the patient been advised of the following? 1.Cataract surgery is only necessary if your quality of life is affected.
2.Cataract surgery is usually very successful but, as with any operation, complications may occur. There is a less than 1% chance of the
vision being worse after surgery. Yes / No
Has patient been given the “Choice” leaflet?
Yes / No
Has patient agreed to surgery and given verbal consent to providers having access to their patient information and clinical records.
Yes/No
Optometrist Signature:
Administration section
Date referral received:
Date patient contacted PCA:
Provider chosen:
582780293
Examination Date:
PCT:
PCA:
Appointment date booked: