Glaucoma Referral Refinement

GLAUCOMA REFERRAL REFINEMENT

Surname: / Other names: / Date of Birth:
Address:
Postcode: / Telephone Numbers:
GP Name: / GP Practice:
THIS PATHWAY IS ONLY FOR PATIENTS REGISTERED WITH C&ECPCT GPs WITH NORMAL OPTIC DISCS. If there are disc changes or the patient is registered with a GP from another area please refer via GOS18 as usual.
IOP
Date / Time / Instrument / RE / LE
Original (from Sight test) / (specify)
Repeat (Must be with Goldmann orPerkins) / Goldmann / 
Perkins / 
Do not refer for IOP alone unless at least one eye is over 21mmHg on BOTH occasions
Visual Fields
Date / Time / Instrument / RE / LE
Original
(from Sight test) / Normal /  / Normal / 
Suspicious /  / Suspicious / 
Repeat
(On different date. Minimum 60 pt Supra-threshold or SITA 24-2) / Normal /  / Normal / 
Inconsistent defect /  / Inconsistent defect / 
Consistent defect /  / Consistent defect / 
Do not refer for Visual Field defect alone unless there is a consistent defect in the same area of the plot on BOTH occasions. If claiming for VF repeat then you must include printouts of both the original and repeated fields.
Patient does not need referral /  / Patient needs referral /  / If referral required, please fill in the details below
Prescription Details
Uncor V / Sph / Cyl / Axis / Prism / Base / VA / Add / Near VA
RE
LE
Please record CD ratios here / RE / LE
Other Information
Claiming For: / √ / Optometrist: / Practice Stamp
Repeat IOP / 
Repeat Fields /  / Signature:
Fields & IOP / 
Post or Fax this form to Patient Choice, DRSS, EagleBridge Health & Centre, Dunwoody Way, Crewe, CW1 3AW
FAX: 01270 509632. Don’t forget to include VF printouts if