Ophthalmology

This is a draft standard eReferral form for Ophthalmology. Final Design may differ.
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The form is designed to be viewed on a computer.

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Patient Information

Surname:

First:

DOB:

Gender:

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Preferred Name:

Sex assigned at birth:

Pronouns:

Preferred language:

Best method of contact:

Referral Source

Please specify:*

Referral Details

Requested Priority:*

Concern(s) / Indication(s) Triggering Referral *

Select all that apply:

Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations*

Ocular Health History

Best Corrected Vision (BCVA)

Right Eye: 20/:*

Left Eye: 20/:*

Important Information to Support Triage and Scheduling

History of Ocular Pathologies*

History of Diabetes*

Notes

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Notes

Referral Preferences

All patients will be triaged to the shortest wait time unless a preference is entered.

Other considerations:

Supporting Documentation

Please attach all relevant records of ocular history, including testing, treatment and surgery

+ Add Attachments

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

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Ontario Health & eHealth Centre of Excellence

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