Minor Eye Conditions Service - Referral Form
Please send referral form by email- contact details are on 2nd page

Section 1   PATIENT INFORMATION (Please complete in BLOCK CAPITALS)	
SURNAME 		Date of Referral                  	
		Date of Birth                       	
FIRST NAME		NHS number                           	
		UBRN                        -                - 	
Title:	Home Tel.	
Mobile/Daytime Tel.	
Address    
	Language Needs:
	
Section 2   PRACTICE INFORMATION (Please use practice stamp if available)	
Referring GP 		
Practice Address           
                                      
 Post Code  	Telephone                                                                                                     		
	Fax		
Use one of the 3 pathways A, B or C for the MEC Service:	
The MECS Service overview can be found here: OVERVIEW	
A: Minor Eye Condition Pathway	
Reason for Referral	Tick	
Red Eye	    ☐	
Watery eye	    ☐	
Itchy eye	    ☐	
Dry eye	    ☐	
Gradual loss of vision over week(s) (if 1-2 days consider urgent referral)	    ☐	
Blurry eyes	    ☐	
Eyelash Problems	    ☐	
Foreign Body	    ☐	
Mild eye pain	    ☐	
Retinal lesions	    ☐	
Other reason – state below in other referral information	    ☐	
Direct A & E referral is required for : Severe ocular pain, Suspected retinal detachment, Retinal artery occlusion, chemical injuries, penetrating trauma, orbital cellulits, sudden loss / dramatic reduction in vision, double-vision. Suspected stroke/TIA discuss with local stroke unit asap; temporal arteritis refer to hospital medical team and not Moorfields Eye Hospital/Ophthalmology Service.
Note: other exclusions: diabetic retinopathy and adult squints.	
B. Suspected glaucoma pathway	
Glaucoma suspect (sudden onset acute glaucoma – refer to A&E) enclose optometrist report if requiring repeat testing for false positives for IOP	    ☐	
	
C. Cataract – Refinement pathway	
Cataract for refinement - enclose optometrist report if applicable	    
☐	

 Other Referral Information:
	
Past Medical History
Please add here:	
Current Medications:	

Other Guidance
The following Optometrists are part of the service in City and Hackney:

Quadrant	Name	Address	NHS.net Email or Fax for referrals	
North West	Infocus Optometrists	163 Stoke Newington Road, N16 8BP	lch.infocushackney@nhs.net 	
North East	Silverman Opticians	176 Clapton Common, Stamford Hill, E5 9AG	lch.silvermanopticians@nhs.net 	
South West	Specsavers (Dalston Cross)	Dalston Cross, Unit 18a, Dalston E8 2LX	specsavers.dalstoncross@nhs.net 	
South East	Rose Opticians	27 Lower Clapton Road, E5 0NS	echub.roseopticianse5@nhs.net
	
City	Specsavers (London Wall)	150-151 Salisbury House Shops, London Wall, EC2M 5QD	specsavers.londonwall@nhs.net	

There will be other sites available in Islington later. Patients can choose which optometrist to arrange an appointment with.

How to refer: 
Use referral form for patient or use leaflet and fill in details of practice etc.

Patient Leaflet

Other information
 
NOTE: If patients have an eye condition that is being regularly monitored by their optometrist or hospital eye service, this will not be covered by MECS; for example: cataracts or glaucoma. 
The service does not replace the routine eye examination, eye tests or prescriptions for spectacles and a sight test will not be performed as part of the assessment or treatment and patients will not be issued with a prescription for spectacles