Working Diagnosis - Glaucoma*Suspect COAGNarrow anglesFrank COAGSub acute angle closurePigment dispersion syndromePseudoexfoliationOcular hypertensionLocation*Select a destinationDestination 1 - 5 milesDestination 2 - 10 milesDestination 3 - 15 milesSelect your practiceSelect the practice that you are working on behalf of. Select your practice*Select a practiceASDA OPTICIAMS (BLETCHLEY)ASK OPTICIANS - WOBURN SANDSBedford Domiciliary SpecsaversBOOTS OPTICIANS (BLETCHLEY)BOOTS OPTICIANS (CROWN WALK -MILTON KEYNES)BOOTS OPTICIANS (MILTON KEYNES) (KINGSTON)CLEARSIGHT OPTICIANSCOSTCO WHOLESALE UK LTD - MANDEVILLE DRIVED W ROBERTS OPTOMETRISTS (BLETCHLEY)D W ROBERTS OPTOMETRISTS (NEWPORT PAGNELL)D W ROBERTS OPTOMETRISTS (STONY STRATFORD)D W ROBERTS OPTOMETRISTS (TOWCESTER)D W ROBERTS OPTOMETRISTS (WOLVERTON)DAVIS OPTOMETRISTS - OLNEYHAMMOND AND DUMMER OPTICIANSHERON OPTICIANS (Premier Opticians)HING OPTICIANS (TP4D6)JOHN LEWIS OPTICIANS MK 9453 (? DAVID CLULOW)OPTICAL EXPRESS [MILTON KEYNES]OPTIMAX LASER EYE CLINIC (MILTON KEYNES)OWL OPTICAL LIMITED T/A M&S OPTICIANS (MILTON KEYNES)PUNCH OPTICIANS LTD - OLNEYSCEATS OPTICIANSSCRIVENS OPTICIANS (MILTON KEYNES)SPECSAVERS (BLETCHLEY)SPECSAVERS (LEIGHTON BUZZARD)SPECSAVERS (MILTON KEYNES)SPECSAVERS (NEWPORT PAGNELL)STONY OPTICALTJ LODGE OPTICIAN LTD WOLVERTONTJ LODGE OPTICIANS LTD BLETCHLEYVISION EXPRESS (MILTON KEYNES)VISION EXPRESS (TESCO EXTRA MK BLETCHLEY)VISION EXPRESS (TESCO EXTRA MK KINGSTON)Patient DetailsHiddenpxid HiddenPatient ID– Fill Out Other Fields –Name* First Last Date of birth DD slash MM slash YYYY AgeGender* Postcode NHS Number Accessibility requirementsAccessibility requirements Hearing difficulties Learning difficulties Mobility issues Visually impaired Sign language / talk to text Driver? Yes Lives alone? Yes Interpreter Yes No Which language?Select a languageAcholiAfrikaansAlbanianAmharicArabicAshanteAssyrianAzerbaijaniAzeriBajuniBasqueBehdiniBelorussianBengaliBerberBosnianBravaneseBulgarianBurmeseCakchiquelCambodianCantoneseCatalanChaldeanChamorroChao-chowChavacanoChuukeseCroatianCzechDanishDariDinkaDiulaDutchEnglishEstonianEspanolFanteFarsiFinnishFlemishFrenchFukieneseFulaFulaniFuzhouGaddangGaelicGaelic-irishGaelic-scottishGeorgianGermanGoraniGreekGujaratiHaitian CreoleHakkaHakka-chineseHausaHebrewHindiHmongHungarianIbanagIcelandicIgboIlocanoIndonesianInuktitutItalianJakartaneseJapaneseJavaneseKanjobalKarenKarenniKashmiriKazakhKikuyuKinyarwandaKirundiKoreanKosovanKotokoliKrioKurdishKurmanjiKyrgyzLakotaLaotianLatvianLingalaLithuanianLugandaMaayMacedonianMalayMalayalamMalteseMandarinMandingoMandinkaMarathiMarshalleseMirpuriMixtecoMoldavanMongolianMontenegrinNavajoNeapolitanNepaliNigerian PidginNorwegianOromoPahariPapagoPapiamentoPashtoPatoisPidgin EnglishPolishPortug.creolePortuguesePothwariPulaarPunjabiPutianQuichuaRomanianRussianSamoanSerbianShanghaineseShonaSichuanSicilianSinhaleseSlovakSomaliSoraniSpanishSudanese ArabicSundaneseSusuSwahiliSwedishSylhettiTagalogTaiwaneseTajikTamilTeluguThaiTibetanTigreTigrinyaToishaneseTonganToucouleurTriqueTshilubaTurkishUkrainianUrduUyghurUzbekVietnameseVisayanWelshWolofYiddishYorubaYupikHiddenSummary Care RecordWe 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.HiddenConsent to access the Summary Care Record?* Yes No HiddenNext stepWhat would you like to do?*Select an actionSend an information letter to the GPMake a referral to secondary careMake a referral to a community serviceReferral destination*Select a referral destinationSample Glaucoma Clinic - 6 miles awaySecondary Care Unit - 6 miles away(1) Test Integeration Ophthalmology Service - 6 miles away(2) Test Integeration Ophthalmology Service - 6 miles awayEMMS Glaucoma Triage Service - 6 miles awayEMMS GLAUCOMA BOOKABLE SERVICE - 6 miles awayEMMS LOW VISION BOOKABLE SERVICE - 6 miles awayEMMS Cataract Triage Service - 6 miles away 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?*Select an actionPx advised to make an appointmentGP to organise testsGP to check informationPlease provide the relevant information for the GPHow quickly does the patient need to be seen?*–RoutineSoonWhere is the patient being referred to?*MKUHBedford MoorfieldsLuton and DunstableNorthampton GeneralListerJohn RadcliffeStoke MandevilleBlakelandsSPA MedicaAddenbrooks 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*–CataractCorneaDiabetic Medical RetinaExternal Eye DiseaseGlaucomaLaser (YAG capsulotomy)Low VisionOculoplastics / Orbits / LacrimalOther Medical Retina (incl ARMD)Squint / Ocular motilityVitreoretinalOtherWhich eye for cataract surgery? First eye Second eye 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*–CataractCorneaGeneral OphthalmologyGeneticsGlaucomaMacula (Macular Degeneration, Retinal Vein Occlusion, Diabetic Macular Oedema)Medical Retina (non-Macular Degeneration, non-Retinal Vein Occlusion, non-Diabetic Macular Oedema)Nurse Practitioner Cyst Clinic (Benign Skin Lesions - Prior Approval Required)Oculoplastics/LacrimalOptometry Contact LensOptometry refractionOrthoptics / Low VisionOrthoptics / Ocular motilityPaediatric ophthalmologySuspected Eyelid Skin CancerVitreo-retinalYAG Laser (Posterior Capsular Opacification only)Is the patient being referred for any of the following? Upper lid dermatochalasis Eyebrow ptosis Benign skin lesion No Yes The patient requires Individual Funding Request Panel (IFRP) approval which should take place via their GP. Click to refer to the patient's GP. Is the patient being referred for surgical management of chalazion? No Yes The patient requires Individual Funding Request Panel (IFRP) approval which should take place via their GP. Click to refer to the patient's GP. What does the patient require? Low vision aides Registration Rehab / social support Select AllHave they previously been registered SI/SSI? Yes No HiddenPediatrics–SquintAmblyopia & refractiveOrthopticsNon orthoptic / amblyopiaOculoplastic condition–TrichiasisPtosisEntropionEctropionLid swellingsNot specifiedIs there corneal involvement?–YesNoReferring for–Vitro macula tractionLamellar macula holeFull thickness macula holeDry macula degenerationWet macula degenerationUnspecified macula problemWhich eyes? RE LE Both eyes GOS 18 FormUpload a GOS 18 form*You must upload a referral form.Accepted file types: pdf, Max. file size: 2 GB.Reason for referralReason for referralAttachmentsImagesOCTs, Fundus images, slit lamp images.RE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, mov, wmv, dcm, Max. file size: 2 GB. LE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, mp4, mov, wmv, dcm, Max. file size: 2 GB. Visual FieldsREAccepted file types: jpg, gif, png, pdf, mp4, mov, wmv, dcm, Max. file size: 2 GB.LEAccepted file types: jpg, gif, png, pdf, mp4, mov, wmv, dcm, Max. file size: 2 GB.