Language
English (US)
Svenska
Doctor Information
Referring Doctor
*
Referring Practice Name
*
Email
*
Phone
*
Fax
*
Address
*
City
*
State/Zip
*
Patient Information
First and Last Name
*
DOB
*
/
Year
/
Month
Day
Phone Number
*
Address
*
City
*
State/Zip
*
Interpreter needed?
*
Yes
No
What language?
Primary Insurance Provider
*
Insurance ID Number
Secondary Insurance Provider
Insurance ID Number
Insurance Group Number
What type of consultation is needed?
*
OCT only (macula)
OCT only (optic nerve head)
OCT only (cornea)
Topography only
Ocular photography only (anterior segment)
Ocular photography only (posterior segment)
Diabetic eye evaluation
Glaucoma evaluation
General eye health care
Other
Additional conditions to be evaluated or notes to the scheduling team
Please attach most recent chart note(s) & describe the conditions to be evaluated and list all patient allergies
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Co-Management Preferences
Following our evaluation, we will communicate any findings and/or treatment recommendations. Please indicate how you would like us to continue co-managing this patient. Regardless, all patients will be sent back to the referring provider to resume general eye care as appropriate.
*
I would like to perform my own medical interpretation and reports (Madelia Optometric will perform technical component only)
I would like Madelia Optometric to perform the medical interpretation and reports as well as technical components
I would like Madelia Optometric to assume treatment for any medical conditions found.
I would like Madelia Optometric to assume all eyecare for this patient.
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