Opthalmology Referral Form

* = Required Information

STAFF: If resident wears glasses bring them. Bring MA card or other insurance card.

Doctor *

Date of Appointment *

Staff Attending *

Name *

Diagnosis *

Date of Birth *

Allergies

CURRENT MEDICATIONS AND TREATMENT ORDERS

Fill out below OR attach a copy of the MAR’s

Medication or Treatment Order

Add Medication or Treatment Order

REASON FOR VISIT

To be Completed by Physician and Returned with the Client: (Print clearly OR attach electronic appointment summary)

Check all services provided at this visit

Glaucoma Pressure

Pressure OD

Pressure OS

Fundus

Refraction

Diagnosis

New Orders

MEDICATION CHANGES (fax this form to pharmacy if yes is checked in any box below)

Medication Increased?

Yes

Name of med(s)

Dose/Time

Medication Decreased?

Yes

Name of med(s)

Dose/Time

Medication Added?

Yes

Name of med(s)

Dose/Time

Medication Discontinued?

Yes

Name of med(s)

Dose/Time

Please Note:

1. Your signature indicates review and renewal of all current orders unless changes are indicated.

2. Your signature indicates you have reviewed these findings with the resident / staff.

3. Please attach prescriptions for all medication changes or call our pharmacy directly.

Date

Physician’s Signature *

Next Appointment