Referral Form | Cornwall LASIK

Name *

Medicare Number

Date of Birth (MM/DD/YYYY) *

ADDRESS *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone Home and Mobile if Available *

Email *

Optometrist

Family Doctor

Who Reffered You *

Referred by Family DoctorReferred by the OptometristSelf Referral or by Family MemberReferred by Emergency DoctorReferral by other doctors

Uregency of Referral *

EmergencyUrgentSemi UrgentNot Urgent

Main complaint or reason for the consultation *

Blurry visionItchy, burning, and dry eyeGlaucoma: suspect of family historyRetina problemsFloaters and flashesI want to get rid of my glasses (refractive surgery)I have cataracts and want them removedI need BotoxI have a skin tag or a cyst or something that I want removedI want my eyes checkedOthers (details in the message field)

Other Complaints:

List of medications, doses and why you take them?

Current Medical Problems

DiabetesHypertensionCholesterolCardiac ProblemsLung ProblemsStomachProstateCancersBone and JointAnxiety or DepressionStrokesHearing ImpairmentOthers (Explain in the medication field)

Other health problems that you know that you have

Eye Problems

CataractLens ImplantsGlaucomaPutting Glaucoma DropsRetina ProblemsDiabetic RetinopathyIntraocular InjectionsHad Lasers Eye SurgeriesDry eyesOthers (Explain below)

Eye problems that you know you have

Glasses or Contacts prescription if known

Refractive surgery assessment (check all that apply)

I wear contactsI did wear contacts but stoppedI am interested in getting rid of my glassesI have tried monovision with contact lensesI am prepared to see some halos around lights at night, if I could have good distance vision during the day and good near vision for reading, both without glassesI do you spend a lot of time in bright sunlightI do wear sunglassesI have had a previous assessment to have Laser Vision CorrectionI read without glassesI drive without glasses

Message and other notes

Instructions for the Visit (Checklist) *

Please check off each item to be able to submit the formPlease bring a driver as your pupils might need to be dilatedBring your health cardBring a list of medicationsBring the lens implant cards if you had already a surgery doneIf you had previous Laser Vision Correction, please bring any details that you can about the surgery or at least your prescription from before the surgeryDo not wear contacts to the visit. If you are coming for a cataracts assessment, you have to be out of contacts for 72hrs. The longer, the better. RGBs needs weeks without the Contacts for the cornea to go back to normal.Some testing methods are not covered by Medicare, might require out of pocket payment.If your Visit/communication is of an emergency nature, please go to the ER at Cornwall Hospital, they know how to reach us in these situations.

Days of the week you PREFER to be booked on?

MondayTuesdayWednesdayThursdayFridayNo difference, any day is okay

Days to AVOID being booked on

MondayTuesdayWednesdayThursdayFriday

Time of the Day You prefer to be booked around?

Early Morning (we start at 7AM)MorningNoonAfternoonLatest Possible (After work)No Difference, Any time is okay

Instructions We will try to accommodate these days and times preferences as much as we can. Please accept our apologies if we can't due to scheduling conflicts and availabilities.

SELF REFERRAL FORM

Please fill out the form and send to us

Personal Details

Referral Details

Health Details

Eye Details

Other Details

Visit Preparation

Booking Preferences (Will try to Accommodate)

Verification

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