Clinical Referral Form

Please complete the below referral form in as much detail as possible.
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Alternatively please click here to upload a referral document directly.

Fields marked with an asterisk (*) are required.

Referral To*

Priority*

Practice Name*

Referring Optometrist / Optician*

Referrer Email*

Optometrist Address*

Street Address*

Address Line 2

City*

Post Code*

Patient Name*

Date of Birth*

Patient Telephone Number*

Patient Email Address*

Patient Address (First Line)*

Address Line 2

City*

Post Code*

Other Information:

Referral Specifications: Please provide as much detail as possible

Right Eye

VA Unaided:VA Corrected:Near VA:

Sphere:Cyl:Axis:

Near ADD:

Additional Information:

Left Eye

VA Unaided:VA Corrected:Near VA:

Sphere:Cyl:Axis:

Near ADD:

Additional Information:

Permission Claririfcation: I have the patients permission to retain their medical information and share it with Eye Surgery Scotland for clinical and medical use. The patient will not be contacted without their consent for any other reason than in follow up of their ongoing medical care and long term health benefits.

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In the interest of best practice and patient record confidentiality we request that appropriate files be emailed to us directly. Upon clicking submit you will be sent an email to your given address. Please respond to this email with the relevant files attached. Using this two factor authentication method we ensuring GDPR and NHS compliant records for patients and professionals.

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