Select your practiceSelect the practice that you are working on behalf of. Select your practice(Required)Select a practiceJohnson's Opticians - 123 Springvale RoadMiles' Opticians - 123 Springvale RoadSS Opticians - 123 Springvale RoadPatient DetailsHiddenpxid HiddenPatient ID– Fill Out Other Fields –Name(Required) First Last Date of birth(Required) DD slash MM slash YYYY AgeGender(Required) Postcode(Required) NHS Number(Required) Essential InformationTreatment(Required) Continuous Non-continuous Date Hydroxychloroquine (or Chloroquine) commenced(Required) DD slash MM slash YYYY Total duration(Required)Interval(Required)DaysMonthsDaily dose (mg)(Required)Body weight (kg)(Required)Tamoxifen use (past or present)(Required) Yes No Renal functionGFRDate DD slash MM slash YYYY Other medicationAcutesRepeatsAny known eye conditionAny known condition(Required) Yes No Please give details(Required)