Dry Eye Clinic Referral Automated Submission Form

Dry Eye Clinic Referral Automated Submission Form
Date

MonthDayYear
Referring Doctor's Name

First NameLast Name
Physician PRAC ID Billing Number (optional)
Office Phone Number
Office Fax Number
Office Email
example@example.com
PATIENT INFORMATION
Patient Name

First NameLast Name
Patient Alberta Health Number
Sex

MaleFemaleOther (please specify)
Date of Birth

MonthDayYear
Date
Patient Phone Number
Patient Alternate Phone Number
Patient Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
REFERRAL REASON
Referral To:
Please select any that apply to the patient's history:

Sjogren's SyndromeEye surgeryStyes or chalaziaBlepharitisContact lens useGlaucomaNone (If other, please specify)
Please select reason for ocular surface consultation:

Intense Pulsed LightLipiFlow Thermal PulsationBlephexI-Lux Heat & ExpressionAmniotic MembraneAutologous SerumNeeds to be determinedOther (please specify)
Please provide additional relevant referral information:
Please upload any images or files here (e.g. pictures, PDF documents, EMR generated referral doc, etc.) (optional)

Cancelof
Please upload any additional files here (e.g. pictures, PDF documents, etc.) (optional)

Cancelof
Referrals can still be faxed if you wish to (905) 456-9332
Should be Empty:

PATIENT INFORMATION