WKI Ophthalmology Outcome Notes Request
For Physician/Clinic Use ONLY
Patient Info
Patient First Name
*
Patient Last name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Patient Address
Street Address
Street Address Line 2
City
State
Zip Code
Patient Email
example@example.com
Notes Request:
*
I need notes sent
I am sending notes
Other
Please select how you would like to send the notes:
*
File upload
Copy/paste
Other
Please select all of the documents you would like to receive:
*
Notes and images
Images only
Notes only
Other (please specify)
Please select for what time frame:
*
Last visit
Last 3 visits
All visits
Other (please specify)
Please select how you would like to receive your request:
*
Secure Email
Secure Fax
Mail
Other
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Medical History
*If not submitted here, please fax the most recent exam notes and patient demographics face sheet
Requesting Provider Information
Practice Name
*
Name
*
Dr.
Nurse
PA
Prefix
First Name
Last Name
Provider/Practice Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Fax Number
*
Please enter a valid fax number.
Format: (000) 000-0000.
Practice Address
Street Address
Street Address Line 2
City
State / Province
City
Specialty
Ophthalmology
Optometry
Endocrinology
Family Medicine
Oncology
Neurology
Rheumatology
Emergency Medicine
Other
Contact Name (if different)
First Name
Last Name
NPI Number
Additional Information/Comments
Submit
Should be Empty: