Optometrist Referral Form

*This form will only submit once all fields are complete

"*" indicates required fields

Priority:

Referral to:

Practice name:

Referring optometrist/optician:

Referrer Email:

Optometrist Address

Street Address Address Line 2 City Post code

Patient details

Patient ID:

Patient name:

First Last

Date of birth:

Patient phone number:

Patient Address

Street Address Address Line 2 City Post code

Other:

Reason for referral:

Cataract referrals:

Right eye

Va unaided:

VA corrected:

VA Uncorrected:

sphere:

cyl:

Axis:

Near un:

Near Corr:

Left eye

Va unaided:

VA corrected:

VA Uncorrected:

sphere:

cyl:

Axis:

Near un:

Near Corr:

Please summarise your referral:

Permission check:*

I have the patients permission to retain their medical information and share it with Laser Vision Scotland for clinical purposes. The patient will not be contacted for any other purpose.

Optometrist GDPR:*

I agree to the GDPR data sharing agreement between optometrist and Laser Vision Scotland

Read data sharing agreement

File upload

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 25 MB, Max. files: 10.

Optometrist Referral Form

*This form will only submit once all fields are complete

Patient details

Right eye

Left eye

Cataracts

Patient

RLE

Optometrist

Info

Account

Optometrist

Account

Patient

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