Hidden

Referral Action

Referral Destination*

Clinic

Location*

Select your practice

Select the practice that you are working on behalf of.

Select your practice*

Patient Details

Hidden

pxid

Hidden

Patient ID

Date of birth*

Age

Gender*

Postcode*

NHS Number*

Accessibility requirements

Interpreter required

Interpreter required?*

Which language?*

Hidden

Summary Care Record

We can send the patient's Summary Care Record held by their GP practice with the referral. The patient must give their consent to allow us to access the SCR.

Hidden

Next step

What would you like to do?*

Referral destination*

You are trying to send an information letter to the GP. Click here to go to the information letter form.

What would you like the GP to do?*

Please provide the relevant information for the GP

How quickly does the patient need to be seen?*

You are making an urgent or emergency referral. The CCG has mandated that you transfer to Booked Urgent Services (BUS) referral form, click here to transfer.

Which clinic*

You have selected the Glaucoma pathway. The CCG has mandated that you transfer to the Glaucoma referral form, click here to transfer.

You have selected the Low Vision pathway. The CCG has mandated that you transfer to the Low Vision referral form, click here to transfer.

Which clinic*

The patient requires Individual Funding Request Panel (IFRP) approval which should take place via their GP. Click to refer to the patient's GP.

Hidden

Pediatrics

Oculoplastic condition

Is there corneal involvement?

Referring for

Hidden

Practitioner

Hidden

User Role

Hidden

Practitioner ID

How long have they had symptoms?

Working diagnosis

Refraction and visual acuities

A referral justification must be provided if the VA is 6/12 or worse (0.3 or worse).

To refer for a second eye, 1 VA must be 6/24 or worse.

Please provide a referral justification for cataract surgery

Ocular examination

Ocular Motility

Ocular Motility Comments

Pupils

Pupils comments

Amsler Chart

Enter right eye and left eye below.

Right Eye

Left Eye

Amsler Chart Comments

Colour Vision

Enter right eye and left eye below.

Right Eye

Left Eye

Colour Vision Comments

IOP

Method

Right Eye (mmHg)

Average reading

Right Eye

Left Eye

Macula Comments

Hidden

Treatment

Attachments

Additional information / comments

Any additional information

Images

OCTs, Fundus images, slit lamp images.

[Draft] BLMK GOS

Select your practice

Patient Details

Accessibility requirements

Interpreter required

Summary Care Record

Next step

Practitioner

Refraction and visual acuities

RE

RE

LE

LE

Ocular examination

Ocular Motility

Pupils

Amsler Chart

Colour Vision

IOP

Dilation

External

Anterior Segment

Angle Assessment

Lens

Vitreous

Discs

Periphery

Macula

Attachments

Additional information / comments

Images

Visual Fields