Glaucoma Clinic Referral Automated Submission Form

Date

Referring Doctor's Name

First Name Last Name

Physician PRACI-ID Number (optional)

Office Phone Number

Office Fax Number

Office Email

example@example.com

Patient Name

First Name Last Name

Patient Alberta Health Number

(eg. 1234 567 890 - XX)

Sex

Male Female Other (please specify)

Date of Birth

Date

Patient Phone Number

Patient Alternate Phone Number

Patient Address

Street Address

Street Address Line 2

City Province

Postal Code Country

Referral To:

Please select one:

Glaucoma Suspect Ongoing Glaucoma Care Other (Please specify )

Last known refractive error (OD) (optional)

Last known refractive error (OS) (optional)

Last measured IOP (mmHg) and Central Corneal Thickness (if available) (optional)

Last measured C/D ratio (horizontal/vertical) (optional)

Gonioscopy or Anterior Segment OCT performed?

Yes No Other (please specify)

Please provide additional relevant referral information: (optional)

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

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Glaucoma Clinic Referral Automated Submission Form

PATIENT INFORMATION

REFERRAL REASON

Referrals can still be faxed if you wish to 587 324 2824