Eye health professional referrals

Client Details

Gender
FemaleMale

Title

Address (inc. postcode)

Living Situation
AlonePartner/spouseOther relativeResidential careSheltered accomm.Not known

Contact Number

Ocular History

Registered
Severely sight impairedSight impairedNot registeredNot known

Sight loss condition

Date of last eye examination

Best binocular vision
DistanceNear

Visual Acuities

Other relevant investigations and/or treatments

General Health

GP Practice

General health and other disabilities

Reported difficulties

Tick all that apply:
ReadingWritingTaking medicationShoppingCookingTelevisionLandline telephoneCraftsTelling timeGlareLightingUsing mobile or computer
Help most needed with:

Preferred low vision clinic(s)

Wadebridge (once a month)Helston (once a month)Falmouth (every 6-8 weeks)Redruth (once a month)Penzance (once a month)St Austell (twice a month)Truro (weekly)Home visit – (by exception only - £25 charge for travel)

Other iSightCornwall services required

Technology and gadgets at homeSocial activitiesEveryday living aidsAdvice and guidanceEye clinic supportEmployment support

Any other information

Disclosure of Information and Confidentiality Agreement

All personal information provided by you will be treated strictly in terms of the Data Protection Act 2018. When we ask you for specific details, we’ll always be clear about why we need them and make sure that your personal information is kept secure. We will not sell your details to any third parties for marketing purposes. We will seek your permission if we need to share your information to make referrals with trusted health and statutory organisations, such as social services and NHS health providers.

Client signature
Signed:

Date:

If client not present please tick box to indicate verbal consent given:
Consent given

Optometrist details

Signed:

Practice details:

Date: