OFFICIAL-SENSITIVE PERSONAL

OFFICIAL SENSITIVE PERSONAL

Medical in Confidence (when completed)

OPTICIANS REPORT

If you wear glasses/contact lenses this form must be completed by your optician and emailed to Capita no
later than 3 days before your face to face medical, but NOT before you have received your appointment.

Additionally, all candidates applying for the role of firefighter, must submit a completed form regardless of
whether you usually wear glasses/contact lenses.

Failure to comply will mean you are found temporarily unfit and you will be unable to continue with the medical
process until this has been emailed to Capita.

The completed form should be emailed to Recruitment.medicals@capita.co.uk

Surname: First Name: URN:

Date of Birth: Age: AFCO:

FOR COMPLETION BY OPTOMETRIST / OPHTHALMIC SPECIALIST

Please complete all boxes to avoid delays in the recruitment process. The recorded corrected vision must
be using opticians lenses/spectacles not contact lenses

Assessment of refractive error and near vision

Dist.
Vision Dist N6 at N12 at
Sph Cyl Axis Prism
Unaided Corrected 33 cm 33cm

R 6/ 6/
Y N Y N
L 6/ 6/

Comments

Practice Stamp

Signature

Name:

Date of test:

OFFICIAL SENSITIVE PERSONAL

Medical in Confidence (when completed)
OFFICIAL-SENSITIVE PERSONAL