Patient Referral. Date: Doctor s Name: Phone: Contact Fax: Preferred Method of Communication (circle one): Fax Letter

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Juliana Greer
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Patient Referral Date: Doctor s Name: Phone: Contact Email: Fax: Preferred Method of Communication (circle one): Email Fax Letter Patient s Name: Phone: DOB: Please check your doctor preference:

1 Patient Referral Date: Doctor s Name: Phone: Contact Fax: Preferred Method of Communication (circle one): Fax Letter Patient s Name: Phone: DOB: Please check your doctor preference: Savannah Brunt, Teresa Carlson, Starck Johnson, MD Crystal Kasper, Ketty Lee, Tom Politzer, Robert Prouty, Richard Stewart, MD Carl Tubbs, MD First Available Reason for Referral: Chief Complaint, Ocular History, Visual Acuity, Intraocular Pressures, etc. Please Indicate: InSight LASIK: Refractive surgery consult Cross-Linking consult ICL Consult Insight Vision Group: One-time consult Diagnose and treat this problem Co-manage Follow patient along with me Transfer complete management I will follow for routine care only Visual Fields: If you would like us to do testing only, please circle what you would like done: Nerve Fiber Analysis: For Cataract Surgery Referrals Only: New technology IOLs, LenSx, and ORA were discussed with patient I recommend the following for my patient: Standard IOL Toric Package Restor Package LenSx ORA LenSx and ORA Trulign Toric-Accommodating Package Monovision: Distance eye is Crystalens Package Mono Target: _ Humphrey SWAP - Goldmann - FDT - Matrix Cirrus (Zeiss) or Avanti (OptoVue) OCT of ONH & macula scan (GCC) Avanti Angle OCT Scan - Digital fundus photos Immersion A-scan IOL master High Resolution B-scan Endothelial Cell Count Pentacam Visante OCT InSight LASIK Parker ~ P: F: Boulder ~ P: F: Insight Vision Group Parker ~ P: F: Lowry ~ P : F: Boulder ~ P: F: Longmont ~ P: F: Fort Collins ~ P: F: Lakewood ~ P: F:

2 LASIK/PRK/ICL M easurements Parker Fax: Boulder Fax: Patient First Name: Last Name: Allergies: Age: Pre-Surgery Evaluation Date UCVA 20/ 20/ Current Rx BCVA 20/ 20/ Manifest Zone Quick Pachymetry Cycloplegic Pupil Size (scotopic) WTW: Dilation: Cyclogyl 1% 0.5% Trop. 1% Phen. Dominant Eye APD Yes No Pentacam K s or X / X X / X Angles Open Narrow Contact Lens Wearer? Yes No Type: Date Last Worn: Stable Yes No Ocular Assessment Status Lids/ Conj Dry Blepharitis Dry Blepharitis Cornea Opac Neo Dyst Opac Neo Dyst IOP Lens Opacity Opacity Pentacam/ Topography Disc 0. Rd. Tilted Myopic Conus CL Warpage Pathology 0. Rd. Tilted Myopic Conus CL Warpage Pathology Macula Myopic Degen Myopic Degen Peripheral Retina Lattice Holes RD Lattice Holes RD Doctor s Signature and Date Name: Date F/U Surgery Plan OU LASIK PRK Primary Enhance Monovision: Yes No Ziemer Allegretto Near Eye Mono Amt.

3 Lasik Post- Op Evaluation Referring Doctor: P lease FAX completed form to: Parker: Boulder: Name (First/Last): Age: Surgery Date: Primary Enhancement History Happy Unsure Unhappy Happy Unsure Unhappy 1 Day Meds AT s x a day AT s x a day 10 Day Acuity UCVA 20/ UCVA 20/ UCVA OU 20/ 2 Mo Flap Good DLK SPK EI Debris Good DLK SPK EI Debris Today s Date Doctor s Signature 1 Day 10 Day 2 Mo History Happy Unsure Unhappy Happy Unsure Unhappy Meds AT s x a day AT s x a day Acuity UCVA 20/ UCVA 20/ UCVA OU 20/ Flap Good SPK Debris Good SPK Debris DLK EI DLK EI Notes Today s Date Doctor s Signature

PRK/ ASA Post- Op Evaluation Referring Doctor: Please FAX completed form to: Parker: 720.880.6460 Boulder: 303.593.

4 PRK/ ASA Post- Op Evaluation Referring Doctor: Please FAX completed form to: Parker: Boulder: Name (First/Last): Age Surgery Date: 1 Day 3 Day History Happy Unsure Not Happy Happy Unsure Not Happy 10 Day Meds AT s x a day AT s x a day 1 Mo Acuity UCVA 20/ UCVA 20/ UCVA OU 20/ 3 Mo 6 Mo 20/ 20/ Cornea Doctor s Signature: Today s Date 1 Day 3 Day 10 Day 1 Mo 3 Mo 6 Mo History Happy Unsure Not Happy Happy Unsure Not Happy Meds AT s x a day AT s x a day Acuity UCVA 20/ UCVA 20/ UCVA OU 20/ 20/ 20/ Cornea Doctor s Signature: Today s Date

5 Cataract / YAG Post Op Form Referring Doctor: Today s Date: // Date of Surgery: // Patient Name: Date of Birth: / / Surgeon: Starck Johnson Fax To: Parker ~ Richard Stewart Boulder ~ Carl Tubbs Lowry ~ Date of Exam: / / Post-op: 1 day 1 week 1 month 3 month other: Type of IOL: Post Op Meds: - UCVA: PH: IOP: am / pm MR: x Cornea: Incision: Open Edema: None Trace Striae: None Trace Anterior Chamber: Cells/Flare: Trace Pupil: Round Irregular IOL: Centered Decentered Posterior Capsule: + Haze + Wrinkles Macula: CME other: Date of Exam: / / Post-op: 1 day 1 week 1 month 3 month other: Type of IOL: Post Op Meds: - UCVA: PH: IOP: am / pm MR: x Cornea: Incision: Open Edema: None Trace Striae: None Trace Anterior Chamber: Cells/Flare: Trace Pupil: Round Irregular IOL: Centered Decentered Posterior Capsule: + Haze + Wrinkles Macula: CME other: Comments:. Dr. Signature:

Pearls for the Refractive Technician Fadiah Alkhawaldeh, IMBA, COT, ROUB

$Pearls for the Refractive Technician Fadiah Alkhawaldeh, IMBA, COT, ROUB$ Pearls for the Refractive Technician Fadiah Alkhawaldeh, IMBA, COT, ROUB Cleveland Clinic Cole Eye Institute OOS, Columbus, OH February, 2014 alkhawf@ccf.org NO FINANCIAL DISCLOSURES A Puzzle of an Eye