Refer a Patient
OXSIGHT Event Consent Form
Preferred method of contact
Full address with postcode or Region
Do you have a pacemaker or implantable cardioverter defibrillator (ICD)?
Have you ever had any history of epilepsy or seizures?
Current Mobility Aids
Current prescription if known
Patient PD (measured today)
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
Did the patient benefit from the glasses?
Which glasses did the patient try?
Are you registered? Please select.
Severely Sight Impaired (Blind)
Any other known medical conditions.
Your employment status? Please select one.
Outcome of demonstration
Details of low vision groups attended
Details of patient's clinical support (hospital, clinic, etc)
Name or initials of demonstrator
Please check the appropriate box(es) to give your consent. You may consent to one purpose without consenting to any other purpose.
I consent to OXSIGHT using information about my health for the following purposes:
To find out if I am able to attend a clinic.
To carry out an initial assessment of the suitability of OXSIGHT’s products and services for me.
To assess whether my other mobility devices can be combined with OXSIGHT’s products and services
To carry out research to help improve and develop OXSIGHT’s products and services
I consent to OXSIGHT sharing information about me with clinicians 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
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, John Eccles House, Oxford Science Park, Oxford, OX4 4GP, marking your letter for the attention of Rob Evans.
Declaration of Parent or Guardian / Carer or Helper
I am a parent, guardian, carer or helper.
Parent / Guardian Name
Parent / Guardian Email
Parent / Guardian Address
Please check the appropriate box below.
I confirm that I am the parent or guardian of the person whose health information is given in this consent form and that the consents given above are given with my knowledge and agreement.
I confirm that I am assisting the person whose health information is given above and that the consents given above are given with that person’s knowledge and permission.
Refer a Patient
Sandy Lane West
1-15 Clere Street
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