Referral Request Form

Referral Request Form

0 www.northtorontoeyecare.com Fax: (416) 748-8582 | Phone: (416) 748-2020 | Email: [email protected] Ocular GTA NW (Main Office) 2065 Finch Ave West, Suite #400 M3N 1W8 Physicians & Central GTA (Surgical Center) 2 Champagne Drive, Unit C2 M3J 2C5 Surgeons North York 7 Elmwood Ave M2N 6R6 PLEASE CIRCLE: Please complete contact and patient information. URGENCY: □ Same Day □ ASAP □ Routine □ Follow Up T. Rabinovitch PLEASE INFORM PATIENT TO BRING CURRENT LIST OF MEDICATIONS, EYE DROPS & Cataract Surgery PLEASE ADVISE PATIENT OF TWO POSSIBLE APPOINTMENTS (PRELIMINARY TESTING & DOCTOR EXAMINATION) Refractive Surgery Cornea & Uveitis Last Name: ________________ First Name: ________ DOB (Y/M/D): First Name: _______________________________________ Phone #: ____________________ Address:_ J. Waisberg OHIP: _ Version Code:Version Ophthalmology Referring Doctor: Dr. Dry Eye Disease Cosmetic Botox Address: Postal Code: T Fax: Tel: _____ _________ REFRACTIVE SURGERY M. Azadeh GLAUCOMA High IOP Lasik/PRK Consult CATARACTS PRIVATE OHIP Cataract Surgery Ophthalmology Disc Cupping RLE/CLE Premium Lens VF Field Loss ICL TRIFOCAL/EDOF Narrow Angles FEMTO Cataract Surgery CORNEA Keratoconus/CXL SLT/LPI N. Pesin _______________________________________ PCO (laser on site) (Performed on site) Keratitis Cataract Surgery________________ OD OS OU Ophthalmology Corneal Ulcer OCULOPLASTICS AMD DRY WET Pterygium Chalazion/Lesions/Cyst INFLAMMATORY Hole/T ear/Detachment Blepharoplasty DISEASE RETINA Conjunctivitis T. Hess ERM Ocular Rosacea Oculoplastics Diabetic Retinopathy Episcleritis/Scleritis Cataract Surgery Ptosis Macular Edema Uveitis/Iritis Entropion/Ectropion Choroidal Nevus Cellulitis Punctoplasty Retinopexy/Focal/Barrier TESTING /PRP Laser (on site) Visual Field/OCT BOTOX V. Lam Blepharospasm Uveitis, Cataract & DRY EYE MTO Hemifacial Spasm Cornea Surgery Tear Film Analysis Pentacam Topography Hyperhidrosis Lipiflow/IPL OD OS OU Cosmetic/Fillers Tearing/Blocked Duct T. Le OD OS Cataract Surgery Ophthalmology BCVA Paediatric IOP REFRACTION G. Yau Additional Information: Medical Retina Cataract Surgery NO PREFERENCE For EMERGENCIES please contact 416-748-7116 or 416-748-2020 ext. 0 Please feel free to fill out a referral form on our website at www.northtorontoeyecare.com Please direct your patients to our patient education videos available on our website .

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