dateoflastsighttestmustbe completed.dd/mm/yy · primary care trust receiving relevant gosi or gos...

At least oneeligibility

criteria mustbe ticked toindicate whyan NHS test isbeing claimed.

If the form is signed by a parent, carer or guardian they must print theirname. If the parent, carer or guardian's address is different to the

patient then they must also print their address

One of these boxesmust be checked.

Date of last sight test must becompleted. dd/mm/yy

If the patient has an HC3, thevalue must be entered here.

One of these boxesmust be checked.

Date of patient signature must be the date ofcollection of second pair as stated in the supplier'sdeclaration if two pairs have been supplied or date of

collection of first pair if only one pair has beensupplied

Either glassesor contactlenses mustbe checked.

Either newprescription or fair

wear and tear must beticked.

Supplement mustmatch the valueentered in part 1

Claims must have avalue in either (1) or

(2)

If supplements arebeing claimed valuesmust be entered.

It isn't acceptable toenter a total claimvalue without

completing the otherboxes as required.