London NHS: Cataract choice – Referral template
PART I: Information for Cataract Referral Centre
PART II: Information GP (No action required by GP).
Tick as appropriate.
PART III: To be given to patient.
SURNAME
ADDRESS
OTHER NAME(S)
POSTCODE
MOB. NUMBER
Date of birth
TEL. NUMBER
NHS No.
PRESCRIPTION DETAILS FROM CURRENT SIGHT TEST.
Unaided
Vision
Sph
Cyl
Axis
Prism
Base
Date
Best
corrected
VA
Date
Add
Near
VA
Previous
corrected
VA
Near
VA
RE
Mydriatic used:
Yes
No
LE
PLEASE COMPLETE BELOW AS APPROPRIATE
Disc appearance:
Intraocular pressure:
RE
RE
mmHg
LE
LE
mmHg
Contact tonometry/NCT. Equipment
REFRACTIVE HISTORY/MEDICATION/OTHER RELEVANT OCULAR PATHOLOGY/COMMENTS:
The patient can be referred direct to the Hospital Cataract Services if the answer to each of the following questions is 'Yes'
Yes
No
1. Does the patient have a problem with their vision caused by cataract?
2. Does the visual impairment affect the patients quality of life?
3. Does the patient understand the risks and benefits of surgery (see guidelines)?
4. Does the patient wish to consider having cataract surgery?
5. I have told the patient they have a cataract and discussed management options.
6. The patient wishes to be referred direct to hospital for cataract surgery.
Please give the patient an information leaflet on cataract
GP Details
Name:
Address:
Referring Optometrist/OMP Details
Name:
Practice:
PCT:
Tel:
Instructions to GP:
Referral Instructions to Optometrist:
Part II is for your information only. No action
required, but additional useful information can
be sent to the hospital (once you know where
they have been referred) stating that the
patient has already been referred through the
cataract referral centre.
Fax/Post Part I to Cataract Referral Centre:
FAX:020 8298 6762 or Post: Cataract Referral Office, 221 Erith Road, DA7 6HZ
Keep fax original/take a copy for your records
Send Part II to GP
Give Part III to the Patient
Send Part IV to Payment Agency
Patient Declaration
I confirm I have been counselled about cataracts and their possible treatment. I would/would not* like to discuss surgery with an
Ophthalmologist. I am happy for information to be passed back to the Optometrist (OMP) and to the above information being collected
for the purpose of audit and ensuring best practice amongst Optometrists (OMP's).
Signed ___________________________________________
Date ________________
* delete as applicable
This form can be folded to show the GP’s address in a windowed envelope
London NHS: Cataract choice – Referral template
PART IV: Copy to be sent to Payment Agency
SURNAME
ADDRESS
OTHER NAME(S)
POSTCODE
MOB. NUMBER0
Date of birth
TEL. NUMBER
NHS No.
The patient can be referred direct to the Hospital Cataract Services if the answer to each of the following questions is 'Yes'
Yes
No
1. Does the patient have a problem with their vision caused by cataract?
2. Does the visual impairment affect the patients quality of life?
3. Does the patient understand the risks and benefits of surgery (see guidelines)?
4. Does the patient wish to consider having cataract surgery?
5. I have told the patient they have a cataract and discussed management options.
6. The patient wishes to be referred direct to hospital for cataract surgery.
Please give the patient an information leaflet on cataract
GP Details
Name:
Address:
Referring Optometrist/OMP Details
Name:
Practice:
PCT:
Tel:
Optometrist Signature
_____________________________________
Name:
Referral Instructions to Optometrist:
Fax/Post Part I to Cataract Referral Centre:
FAX:020 8298 6762 or Post: Cataract Referral Office, 221 Erith Road, DA7 6HZ
Keep fax original/take a copy for your records
Send Part II to GP
Give Part III to the Patient
Send Part IV to Payment Agency
Patient Declaration
I confirm I have been counselled about cataracts and their possible treatment. I would/would not* like to discuss surgery with an
Ophthalmologist. I am happy for information to be passed back to the Optometrist (OMP) and to the above information being collected
for the purpose of audit and ensuring best practice amongst Optometrists (OMP's).
Signed ___________________________________________
Date ________________
* delete as applicable
This form can be folded to show the GP’s address in a windowed envelope.