Optegra Eye Health Care
Shared Care Referral Form
Patient
Title
*
Mr
Mrs
Miss
Ms
Dr
Other
Age
*
DOB
*
-
Day
-
Month
Year
First Name
*
Surname
*
Address
*
Postcode
*
Email
*
Telephone
*
Today’s Prescription
*
UDVA
Sph
Cyl
Axis
BCDVA
UNVA
(40cm)
N
Add
+
BCNVA
R
L
Binocular
Previous Prescription
*
UDVA
Sph
Cyl
Axis
BCDVA
UNVA
(40cm)
N
Add
+
BCNVA
R
L
Binocular
Add details
*
IOP (mmHg)
Pachymetry (if available)
R
L
Patient’s current method(s) or correction
Glasses
*
Single Vision (D)
Single Vision (N)
Bifocal
Varifocal
Contact Lenses
*
Gas Permeable
Soft
Multifocal
Monovision
Distance Eye
Distance Eye?
*
R
L
What is the Patient’s priority and motivation towards vision correction?
*
Additional Relevant information: e.g. past eye history, medical history, patient expectations, examination findings...
*
In your opinion, which vision correction approach could best serve your patient’s visual requirements;
*
Cataract (monofocal)
Refractive Cataract (toric or multifocal)
Laser vision Correction (Age 21-45 pachymetry>45oum, Age >45 interested in LVC)
Implantable Contact Lens (ICL) (Age 21-45 prescriptions over -12D, or over +4D)
Optometrist Name
*
Optometrist Practice
*
GP Name (if available)
GP Practice (if available)
By Signing Below:
I have referred to the consultant indicated above for expert advice & further discussion on vision correction treatments under the governance of Optegra Eye Hospital.
I understand that the initial consultation and usual scans will be performed free of charge.
I am happy for this patient to be referred to my care for future examinations as may be recommended by the consultant and follow up outcome data will be shared with the treating consultant and Optegra Eye Hospital.
Optometrist Name
*
Optometrist Signature
*
Date
*
-
Day
-
Month
Year
Submit
Should be Empty: