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PPwT First and Second Eye Cataract Surgery

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					                                                                                                                 NHS North West London

                                  PPwT form – First and Second Eye Cataract Surgery

                         This form replaces all previous ones that relate to this procedure.
This form confirms that the patient meets the NW London PPwT criteria. A completed form submitted to the email
                                         address below supports funding.

                           The criteria are outlined at: www.westminster.nhs.uk/English/about-
                            us/northwestlondon/Pages/ifrservice_procedures_covered.aspx.

       To register this referral, email it to PPwTNW.London@nhs.net only using your nhs.net email account.
                  Also, send a copy of this form to the normal referral route that you have locally.
             If you wish to send an accompanying letter, please do so. All referrals must be e-mailed.

                                            DO NOT PUT THIS FORM IN THE POST

PATIENT                                                                     REFERRER
                 «PATIENT_Forename1»                                                                   «PATIENT_Registered_GP»
Name                                                                        Name
                 «PATIENT_Surname»
Address          «PATIENT_BlockAddress»                                     Address                    «PRACTICE_BlockAddress»
Telephone        «PATIENT_Main_Comm_No»                                     GP practice code
DOB              «PATIENT_Date_of_Birth»                                    Telephone                  «PRACTICE_Main_Comm_No»
NHS number       «PATIENT_Current_NHS_Number»                               Fax
Gender           «PATIENT_Sex»                                              E-mail
                                                                            Date of referral           «SYSTEM_Date»

LANGUAGE                                                                      NHS TRUST
Interpreter      YES          NO                                            Trust (preferred
required?                                                                   provider)
Language                                                                    Has the patient
                                                                            previously visited         YES           NO
Ethnicity                                                                   this hospital?

THRESHOLDS FOR TREATMENT
1) Does this patient have a best corrected visual acuity of 6/9 or worse in
                                                                                                       YES           NO
either the first or second eye

AND

2) One of:

      Has impairment in lifestyle such as substantial effect on activities of
                                                                                                       YES           NO
       daily living, leisure activities, and risk of falls.

      Surgery is indicated for management of ocular comorbidities e.g.     YES        NO
       control of glaucoma, view of diabetic retinopathy
Other supporting Information for referral - these are merge fields - please edit as required
Current Consultation:-
«CURRENT_CONSULTATION»

Past Medical History:
«MEDICAL_HISTORY»

Medication
             Latest version of the form is available at www.westminster.nhs.uk/English/about-us/northwestlondon/Pages/ifrservice.aspx
                                                              Version 0.1 (20.3.2011)
                                                                                                                NHS North West London
«REPEATS»

Allergies – H/O allergies not recorded
«DRUG_ALLERGY»




END OF FORM




            Latest version of the form is available at www.westminster.nhs.uk/English/about-us/northwestlondon/Pages/ifrservice.aspx
                                                             Version 0.1 (20.3.2011)

				
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posted:5/22/2011
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