GP / Optometrist Referral Form

The following form is encrypted at the time of sending and any referral information entered will be deleted after the appointment has been made for the patient. Patient data is not stored but securely transmitted to Mr Agrawal.

Required fields*

Patient Name*

Date of Birth

Day*

Month*

Year yyyy*

Telephone*

Right Refraction

Right Sphere Right Cylinder Right Axisº Right Corrected Vision*

Left Refraction

Left Sphere Left Cylinder Left Axisº Left Corrected Vision*

Referring GP or Optometrist* GP or Optometry practice* Referring GP or Optometrist Email Address* Comments/reason for referral*

To understand how we will store and use your details please see our privacy policy and cookie notice.

Mr. Pavi Agrawal

Department of Ophthalmology, Queens Medical Centre, Derby Road, Nottingham Nottinghamshire NG7 2UH
Secretary: Sharna Croft - Tel: 07983 434881

Spire Hospital Nottingham, Tollerton Lane, Tollerton, Nottingham NG12 4GA
Secretary: Rebecca Kilburn - Tel: 0115 9377684

BMI Park Hospital, Sherwood Lodge Drive, Burntstump Country Park, Arnold, Nottingham NG5 8RX
Secretary: Dorothy Robinson - Tel: 0115 9662293

COVID-19 UPDATE

GP / Optometrist Referral Form

Right Refraction

Left Refraction

Mr. Pavi Agrawal