Patient Assistance Application

Patient Assistance Application

Please submit this form electronically or via fax to 901-370-2778 along with the patient's exam note. Applications take 7-10 business days for processing. Contact us at info@secf901.org with any questions or concerns.
Patient Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Annual Household Income
Household Size
Date of Exam

MonthDayYear
Date
Chief Complaint
Examination
Best Corrected Visual Acuity (20/) - Distance / Right
Best Corrected Visual Acuity (20/) - Distance / Left
Best Corrected Visual Acuity (20/) - Distance / Both
Best Corrected Visual Acuity (20/) - Near / Both
Glare Visual Acuity OD (If not performed, skip)
Glare Visual Acuity OS (If not performed, skip)
Was refraction performed with cycloplegic agents?

YesNo

	Normal OD	Abnormal OD	Remarks	Normal OS	Abnormal OS	Remarks
External Exam (eye and adnexa)
Internal (media, lens, fundus, etc.)
Neurological Integrity (pupils)
Color Vision
IOP (glaucoma)
Oculomotor assessment

Medical Diagnoses- Please check all that apply

NoneDiabetesHypertensionCancerHyperlipidemiaHeart DiseaseRheumatoid ArthritisLupusOther
Ocular Diagnoses- Please check all that apply

NormalMyopiaHyperopiaAstigmatismAmblyopiaCataract-Nuclear SclerosisCataract-Posterior SubcapsularCataract-CorticalCataract-OtherGlaucomaDiabetic RetinopathyAge Related Macular DegenrationHypertensive RetinopathyOther-Retina
Surgical intervention is requested

ODOSOU
Are you willing to see this patient for their 1 day, 1 week and 1 month post-op appointments?

YesNo
Optometrist / Physician's Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature

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Examination