GOS18       Ophthalmic Referral/Information for GP
Date of sight test	Date of referral (if different)
Optometrist/OMP Name and Practice Address Optometrist Name and Practice Address Post Code: Tel: NHS mail: GP Name and Practice Address Patient details Title: Surname: Forename: Address: Postcode: Telephone: Date of Birth: NHS Number (if known) : GP Action required: (Also see ‶additional information″ below) This letter is for INFORMATION ONLY Patient asked to telephone/visit GP Patient sent to Eye Casualty Advise Referral to Eye Dept (URGENT) Advise Referral to Eye Dept (Routine) CHILDREN: Clinic Type suggested for referral to HES (tick most urgent one) Strabismus and Amblyopia Paediatric non-strabismus Orthoptic (only) ADULTS (16 or older):Clinic Type suggested (tick most urgent one) Cataract Cornea Diabetic Medical Retina External Eye Disease Glaucoma Laser (YAG capsulotomy) Low Vision Oculoplastics / Orbits / Lacrimal Other Medical Retina (incl ARMD) Squint / Ocular motility Vitreoretinal Not Otherwise Specified CLINICAL TERM(S)Enter relevant keyword(s) (these are to help the GP to fi nd correct HES service)
Sph Cyl Axis Prism Base VA Pinhole Add Near Vision Previous corrected VA on (date) Right     Left
Right Eye Left Eye Visual fields Normal/enclosed (if abnormal) Normal/enclosed (if abnormal) Optic nerve heads C:D C:D Intraocular pressure Time:  mm Hg  mm Hg Applanation/non contact/ Other Additional information Cycloplegic refraction Dilated fundus examination GOS 18 Part One – This part must accompany any referral made to an Eye Department

STATEMENT: The reason for this referral has been explained to the patient or guardian who agrees to it. The patient or guardian also consents to information being exchanged between the Hospital Eye Service, their General Medical Practitioner, and optometrist or ophthalmic medical practitioner (delete any not consented to).
If appropriate, Guardian’s name and address
Signed (optometrist/OMP)	GOC/GMC No