Ophthalmology

This is a draft standard eReferral form for Ophthalmology. Final Design may differ.
Please provide your feedback in the form on the right-hand side

The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

Referral Source

Please specify:*

Optometrist/Ophthalmologist

Primary Care

Other

Patient Health History

Clinical Optometry/Ophthalmology Report attached

Best Corrected Vision (BCVA)

Right Eye BCVA: 20/:

Left Eye BCVA: 20/:

Notes

Patient Health History

Optometrists/Ophthalmologists are asked to provide the "Important Information to Support Triage" as either an attachment or entered directly in the form.
Checking off that an attachment has been added will remove mandatory fields.
Supporting Details are included as non-mandatory fields.

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

Brief Description

This mandatory field is meant to describe the relevant patient information, which may include the current history, management, investigations, or expectations of the referral

Cumulative Patient Profile

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

CPP attached separately (if not entered below)

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.

Preferred clinician

Preferred location

Patient willing to travel for shorter wait time

Other considerations:

Supporting Documentation

Please attach all relevant laboratory and diagnostic investigations.

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

+ Add Attachments

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Please provide your feedback in the form on the right-hand side
Ontario Health & eHealth Centre of Excellence

Notes

Referral Source

Selecting the referral source will change the display on the form.
During setup, the listing may decide where referrals will be accepted from and hide options as needed.
Selecting "Primary Care" or “Other” as the Referral Source will prompt the referrer to attach a recent Clinical Optometry Report and basic details
Selecting "Optometrist/Ophthalmologist" will prompt users to provide key clinical details in the Patient Health History section below as an attachment, or in the form itself.

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

Brief Description

This mandatory field is meant to describe the relevant patient information, which may include the current history, management, investigations, or expectations of the referral

Notes