PA Cataract - Co-Management Patient Referral & Consent

Cataract Co-Management Patient Referral & Consent Form
SightMD PA Co-Management*

SightMD PA Co-Management
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Patient Main Phone Number*
Please enter a valid phone number.
Patient Second Phone Number
Please enter a valid phone number.
Patient Email
example@example.com
Insurance Company
Policy Number
RESULTS & RECOMMENDATIONS FROM LAST EXAM

(please fill out this form or send notes from last exam)

Refraction with BVA*

	S	C	A	BVA
OD
OS

	S	C	A	Add
Contact Lens RX (If applicable)

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

NO POST-REFRACTIVELASIKPRKRKHYPEROPICMYOPIC
REFERRING PHYSICIAN NOTES FOR REFERRAL
PATIENT CONSENT FOR CO-MANAGEMENT
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

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Date

MonthDayYear
Date
Witness Signature

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Date

MonthDayYear
Date
Primary Eye Care Doctor Signature*

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Date*

MonthDayYear
Date
Surgeon Signature

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Date

MonthDayYear
Date
File Upload

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Cataract Co-Management Patient Referral & Consent Form