WET AMD RAPID ACCESS REFERRAL FORM Name of Consultant: Hospital Contact Details: PATIENT DETAILS NAME: DOB: HOSPITAL NO: ADDRESS: (If known) CONTACT TEL NOS: GP NAME: GP SURGERY: OPTOMETRIST DETAILS: NAME: PRACTICE: GOC NO: ADDRESS: TEL: FAX: AFFECTED EYE: RIGHT: LEFT: PAST HISTORY IN EITHER EYE RIGHT: LEFT: PREVIOUS AMD RIGHT: LEFT: MYOPIA RIGHT: LEFT: OTHER REFERRAL GUIDELINES PRESENTING SYMPTOMS IN AFFECTED EYE (one answer must be yes, please mark the correct box with an ‘X’) Duration of visual loss: Visual Loss YES NO Spontaneously reported distortion YES NO Onset of scotoma (or blurred spot) in central vision YES NO FINDINGS Best corrected VA (must be 6/96 or better in affected eye) Distance VA RIGHT: / LEFT: / Near VA RIGHT: LEFT: Macular drusen (either eye) RIGHT: LEFT: In the affected eye ONLY, presence of: Macular haemorrhage (preretinal, retinal, subretinal) RIGHT: LEFT: Subretinal fluid RIGHT: LEFT: Exudate RIGHT: LEFT: Comments ADDITIONAL COMMENTS: Formatting/printing/distribution of this form has been sponsored by Novartis Pharmaceuticals UK Ltd. OPT09-004; Date of Preparation: October 2009
WET AMD RAPID ACCESS REFERRAL FORM Name of Consultant: Hospital Contact Details: PATIENT DETAILS NAME: ADDRESS: CONTACT TEL NOS: DOB: HOSPITAL NO: (If known) GP NAME: GP SURGERY: OPTOMETRIST DETAILS: NAME: GOC NO: TEL: PRACTICE: ADDRESS: FAX: AFFECTED EYE: RIGHT: LEFT: PAST HISTORY IN EITHER EYE PREVIOUS AMD MYOPIA OTHER RIGHT: RIGHT: RIGHT: LEFT: LEFT: LEFT: REFERRAL GUIDELINES PRESENTING SYMPTOMS IN AFFECTED EYE (one answer must be yes, please mark the correct box with an ‘X’) Duration of visual loss: Visual Loss Spontaneously reported distortion Onset of scotoma (or blurred spot) in central vision YES YES YES NO NO NO FINDINGS Best corrected VA (must be 6/96 or better in affected eye) Distance VA Near VA Macular drusen (either eye) RIGHT: / RIGHT: RIGHT: LEFT: / LEFT: LEFT: In the affected eye ONLY, presence of: Macular haemorrhage (preretinal, retinal, subretinal) Subretinal fluid Exudate RIGHT: RIGHT: RIGHT: LEFT: LEFT: LEFT: Comments ADDITIONAL COMMENTS: Formatting/printing/distribution of this form has been sponsored by Novartis Pharmaceuticals UK Ltd. OPT09-004; Date of Preparation: October 2009
Electronic-Referral-Form-OPT09-004.docx