Referring Clinician Details Patient Details Surname Name First Name GOC Number Date of Birth Practice Tel. Number Address Mobile Number Referral Date Address Action Required Postcode Urgent – Within 2 Weeks Routine – Within 18 Weeks NHS Number GP appointment required – Referred direct Dr. ESP Self-Referral Referral Reason GP Surgery Anterior Eye Cataract GP Address Cornea / Conjunctiva External Eye Disease Glaucoma Tonometry & Prescription Details LVA Clinic Reading 1 Reading 2 Neuro-Ophthalmology Right Left Right Left Non Specific Eye Condition Date Oculoplastics / Orbital / Lacrimal Time Orthoptics Paediatric ( Under 18 months ) Optic Disc PCO / IOL (Incl. YAG) Instrument Squint / Ocular Motility Vitreo Retinal / Medical Retina (Incl. DMR) IOP Av. Vision Sph Cyl Axis VA Add Prism Base Right Left Previous VA Date Right Left Hospital Preference ESP Preference
Patient Details Surname First Name Date of Birth Tel. Number Mobile Number Address Postcode NHS Number Dr. GP Surgery GP Address Referring Clinician Details Name GOC Number Practice Address Referral Date Action Required Urgent – Within 2 Weeks Routine – Within 18 Weeks GP appointment required – Referred direct ESP Self-Referral Referral Reason Anterior Eye Cataract Cornea / Conjunctiva External Eye Disease Glaucoma LVA Clinic Neuro-Ophthalmology Non Specific Eye Condition Oculoplastics / Orbital / Lacrimal Orthoptics Paediatric ( Under 18 months ) PCO / IOL (Incl. YAG) Squint / Ocular Motility Vitreo Retinal / Medical Retina (Incl. DMR) Tonometry & Prescription Details Reading 1 Reading 2 Right Left Right Left Date Time Optic Disc Instrument IOP Av. Vision Sph Cyl Axis VA Add Prism Base Right Left Previous VA Date Right Left Hospital Preference ESP Preference
evolutio-Referral-Form-2.docx