Consultant Ophthalmologist,
Cataract & Refractive Surgeon

BMedSci BM BS MRCS MRCSEd MRCOpth FRCOphth MMedLaw PgD Cataract & Refractive Surgery

Private Patient Referral Form Cataract Surgery / Lens Extraction

Please be assured that patient data is not stored, but securely transmitted to Mr Alwitry's PA.

Patient Name:*
DOB:*
 / 
 / 
Contact Number:*

Right Refraction:

Right Sphere:*
Right Cylinder:*
Right Axis:*
Right Near Add:*
Right Corrected Vision:*
Right:*

Left Refraction:

Left Sphere:*
Left Cylinder:*
Left Axis:*
Left Near Add:*
Left Corrected Vision:*
Left:*
Patient interested in:*
Patient prefers to be seen at:*
Comorbidity:
Comments:
Referring Optometrist:*
I have read and understand the Amar Alwitry Privacy Statement and am happy for Mr Alwitry's secretary to contact me in response to my referral. *
Optometry practice:*
Optometry Telephone Number:*
Happy to undertake follow-up at 5-6 weeks after second eye under follow-up partnership arrangement?*
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