Optometric Referral Forms

Form A - Optometry Referral Form

Standard Referral via Patient's GP

This form should be used if you are requesting a referral into the Hospital.

Form A is a protected document - please single-click the grey boxes to enter text. Tab between grey boxes, but avoid using the 'enter' key when filling out the px address, as this moves the whole form down - use the tab or arrow key instead.

Where possible, please type referrals. If no computer access is available you will need to write on the forms in CAPITAL LETTERS with a BLACK PEN. Please make the forms as legible as possible.

If a field of vision plot is to be included with the referral, then this should be sent with the referral form to the GP.

The GP practice will attach medical details to the form and forward it on, as appropriate.

It is important to select only ONE clinic type on the form. Please select the clinic type, which seems most appropriate even if there are multiple aspects to your clinical findings. You will need to indicate the priority with which you would like the referral processed.

URGENT - within 4 weeks. ROUTINE - within 12 weeks

Please note that Urgent and Routine are the ONLY options and any other options CANNOT be processed.

Form B (The Optometric Letter To GP Requiring Action Or Advice)

Use this form if you would like to communicate with the patient's GP and/or suggest further medical examinations.
Please record any comments on the form for the attention of the GP and also indicate any advice you have given to the patient. The GP may still wish to refer the patient for further assessment with an ophthalmologist.