Glaucoma Clinic Referral Automated Submission Form

Glaucoma Clinic Referral Automated Submission Form
Date

MonthDayYear
Referring Doctor's Name

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

First NameLast Name
Patient Alberta Health Number
(eg. 1234 567 890 - XX)
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 one:

Glaucoma SuspectOngoing Glaucoma CareOther (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?

YesNoOther (please specify)
Please provide additional relevant referral information: (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 587 324 2824
Should be Empty:

PATIENT INFORMATION