PRACTICE DETAILS
OWNER DETAILS
PATIENT DETAILS
REFERRAL DETAILS
Please concisely outline the reasons for referral (not the entire history) - we really need this information to assess the case. Photos are very helpful for ophthalmology cases (attach below).
OOH Emergency is Ophthalmology only. (Weekdays after 17:30hrs / weekends / public holidays). If your referral is an OOH Emergency, please telephone us as well on 01243 888091.
Patient history
Please attach patient history and any relevant reports, photos, radiographs etc. (FULL PATIENT HISTORY FROM BIRTH is required for us to be able to process insurance claims). Choose a file and then upload it. Repeat process for each file.
Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx.
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