OXSIGHT Clinic Referral
For clinicians only
Current Mobility Aids
Registered Visually Impaired
Sight impaired (partially sighted)
Severely sight impaired (blind)
Date of last eye examination with the Opticians
Current prescription if known
Patient PD (measured today)
Aided Vision if glasses / contact lenses worn
Approximate field of view with the best seeing eye - result using the 1m Crown chart (these are approximate measurements)
less than 5 degrees
greater than 20 degrees
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
I consent to OXSIGHT sharing information about me with opticians who are involved in assessing the suitability of OXSIGHT’s products and services for me
I consent to OXSIGHT contacting me by email to market its own products and services
I consent to OXSIGHT contacting me by phone to market its own products and services
I consent to OXSIGHT Ltd to contact me to gather feedback and discuss any new developments, that they feel would be suitable for me.
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: email@example.com 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
Declaration of Consent
Parent or Guardian / Carer or Helper Consented
Name of Parent or Guardian / Carer or Helper
Sandy Lane West
1-15 Clere Street
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