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Referral Request Form

Thank you for your referral. All referrals will be arranged within 5 working days. If you have not been notified of a consultation date by that time, please contact our office directly.

Please ensure all contact information is filled out.

Note: Do not use this form in case of an emergency!

Patient & Physician Information

Patient Name
Patient Date of Birth
HC Number
Patient Address
Patient Phone Number
Referring Doctor
Physician # (MDs)
Physician Phone
Physician Fax

Reason for referral, please check where appropriate

Glaucoma
High IOP's
Disc Cupping
Field Loss
Narrow Angles
YAG Laser

Retina
PVD/Floaters
AMD Wet Dry
Diabetic Retinopathy (Background)
Diabetic Retinopathy (CSME/NV)
Chorodial Nevus
Retinal Holes/Tears
Retinal Lesion
Macular Hole ERM
Retinal Detachment

Inflammatory Disease
Conjunctivitis
Episcleritis/Scleritis
Uveitis/Iritis

Cornea
Pterygium
Keratoconus
Keratitis
Corneal Ulcer
Cataracts
Patient Ready for cataract surgery
Patient Unsure about cataract surgery
Please include vision:
OD 20/ OS 20/
PCO (needs YAG)

LASIK
Lasik/ PRK Consult

Testing
Pentacam
IOL Master
OCT RNFL
OCT Macula
Visual Field
Please indicate eye(s):
OD OS OU

Other
Lid Abnormalities
Tearing
Diplopia/ Strabismus
Significant Dry Eye
Chalazion
Other
Eye Exam
OD
OS
Best Corrected VA
Refraction
IOP


Clinical History

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Tel: 416-748-2020
 
Toll Free: 1-888-748-2021


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