NJ Cataract - Co-Management Patient Referral & Consent

SightMD NJ Co-Management*

SightMD NJ Co-Management

Patient Name*

First NameLast Name

Patient DOB*

Date

Patient Main Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Patient Second Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient Email

example@example.com

Insurance Company

Policy Number

Refraction with BVA*

Rows	S	C	A	BVA
OD
OS

Name of Referring Physician*

REFERRING PHYSICIAN EVALUATION LOCATION

Referring Physician Evaluation Date

Date

Referring Physician Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Referring Physician Email*

example@example.com

SightMD Surgeon & Location*

REQUESTED SURGERY TYPE*

FEMTOSECOND LASERPHACO WITH IOL

REQUESTED LENS TYPE*

Rows	S	C	A	Add
Contact Lens RX (If applicable)

S/P: (CHECK ALL THAT APPLY): ATTACH RECORDS IF APPLICABLE

REFERRING PHYSICIAN NOTES FOR REFERRAL

Doctor First Name* Last Name* ("my Surgeon"), will be performing Cataract Surgery on me. It is my desire to have Doctor First Name* Last Name* ("my Primary Eye Doctor") perform my post-operative care. I have discussed this election with both my Surgeon and Primary Eye Doctor. I understand that another ophthalmologist or optometrist may lawfully provide post-operative care under applicable state law. I understand that my Primary Eye Doctor will contact my Surgeon immediately if I experience any complications related to my eye surgery and provide progress reports on my recovery during their portion of the post-operative period. I understand that I may also contact my Surgeon at any time and that I can elect to have my Surgeon provide my post-operative follow up care.

Patient Signature

Date

Witness Signature

Date

Primary Eye Care Doctor Signature*

Date*

Date

Surgeon Signature

Date

File Upload

Cataract Co-Management Patient Referral & Consent Form

RESULTS & RECOMMENDATIONS FROM LAST EXAM

PATIENT CONSENT FOR CO-MANAGEMENT