Patient Referral
Idaho Eye and Laser Center
Referring Doctor
*
Office Location
City
Patient Legal Name
*
First Name
Last Name
Gender
*
Male
Female
Birthdate
*
/
Month
/
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Reason for referral:
*
Cataract Evaluation
LASIK
Cornea Evaluation
Glaucoma Evaluation
Retina Evaluation
Diagnostic Testing Only
Other
Diagnostic test requested
*
Example: OCT, HVF, Topography, etc.
Diagnosis for requested testing
*
Example: Glaucoma suspect or ICD-10 code
Have you collected your co-management fee?
*
Yes
No, please collect payment for us on surgery day.
Co-Management Fee
*
$600.00
Glaucoma care
Opinion only
Assume care
Other
Schedule
Idaho Eye Center to make patient's appointment.
Patient is already scheduled.
Other
Exam Findings
Exam Date
-
Month
-
Day
Year
Date
Pertinent Ocular History
Rows
OD
OS
UCVA 20/
Refraction
BCVA 20/
Cycloplegic Refraction
Cyclo VA 20/
Keratometry
Glare 20/
IOP
Exam Findings, Notes, Plan
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