North Central London Diabetic Eye Screening Programme
Barnet, Camden, Enfield, Haringey and Islington
1 Sterling Way
London N18 1QX
Direct Line 020 8887 2352
Direct Fax 020 8887 4498
THIS FORM IS FOR NEW REFERRALS ONLY.
Please DO NOT refer patients with Impaired Glucose Tolerance, Impaired Fasting
Glycaemia, or Gestational Diabetes.
DO NOT use this form if patient has already been referred to this service
Patient NHS Number:~[NHS Number] Patient Mobile Number: ~[Mobile]
Patient Home Number: ~[Telephone Number]
Title: ~[Title] Name: ~[Forename] ~[Surname]
Address: ~[Patient Address Line 1], ~[Patient Address Line 2], ~[Patient Address Line 3],
~[Patient Address Line 4].
Post Code: ~[Post Code]
Date of Birth: ~[Date Of Birth] Gender: ~[Sex]
~[ReadCode:9i~10Y~S1~R~Coded Data|Free Text~0]
Date of Referral: ~[Today...] Practice Code: ~[Practice Code]
Practice Name: ~[Surgery Address Line 1] GP Name: ~[Registered Doctor]
GP Address: ~[Surgery Address Line 2], ~[Surgery Address Line 3], ~[Surgery Address
Post Code: ~[Surgery Address Line 5]
E-mail (please enter a valid nhs.net): ~[Free Text:Please provide an nhs.net email
Diabetes Type & Date of Diagnosis:
Possible reasons for excluding patient from invitations for screening:
Does this patient have no perception of light in both eyes? YES NO
Is the patient physically unable to attend screening e.g.housebound?YES NO
Does this patient have a terminal illness? YES NO
Is the patient under the care of an Ophthalmologist? YES NO
If Yes, is this at a specialist Medical Retina Clinic? YES NO
If Not Sure for what eye condition is the patient being seen? .......................................
If under the care of an Ophthalmologist, which hospital:...............................................
Once completed please email this form to: firstname.lastname@example.org
Or fax it through to: 0208 887 4498
This service is provided by North Middlesex University Hospital NHS Trust
NHS NCL – Converted to EMIS LV – 02.07.2012