Clinic Referral

Patient Name

First Last

Age

Phone

Email

Ocular Diagnosis

Registered Visually Impaired*

Date of last eye examination with the Opticians

Current prescription if known

Right eye	Left eye	Patient PD (measured today)

Aided Visual Acuity

Date today	Right	Left

Other comments

Professionals Initials*

Practice Name*

Practice Address*

Patient Consent

I consent to OXSIGHT Ltd keeping my name, contact details and clinical information on file. For the following: To carry out research to help improve and develop OXSIGHT’s products and services *

Yes
No

I consent to OXSIGHT contacting me by email to market its own products and services*

Yes
No

I consent to OXSIGHT contacting me by phone to market its own products and services*

Yes
No

You may withdraw your consent at any time.
Your withdrawal of consent will not affect the lawfulness of any use of information about you based on consent before its withdrawal.
You have the right to object to the use of your information for direct marketing purposes.
To withdraw your consent or to object to the use of your information for direct marketing purposes please contact: care@oxsight.co.uk or write to us at OXSIGHT Limited, Sandford Gate, Sandy Lane West, Oxford, OX4 6LB, marking your letter for the attention of Information governance officer.

Please indicate below the above information has been acknowledged*

Yes
No

Declaration of Consent*

Patient Consented
Parent or Guardian / Carer or Helper Consented

Name of Parent or Guardian / Carer or Helper*

First Last

OXSIGHT Clinic Referral

Clinic Referral

Patient Consent

Site Map

Oxford Office

London Office

Contact

OXSIGHT Clinic Referral

Clinic Referral

Patient Consent

Site Map

Oxford Office

London Office

Contact

Request a call back from OXSIGHT