Department of Ophthalmology » College of Medicine ...
NEURO-OPHTHALMOLGY APPOINTMENT REQUEST FORM
Dr. Hazem Samy
Eye Specialties Clinic
Shands Medical Plaza
2000 SW Archer Rd. 4th Floor
Gainesville, Fl. 32641
Phone: 352-265-7080 Fax: 352-627-4299
TODAY’S DATE: PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY
Patient Name: DOB: MR#
Address: City: State:
Home #: Work #: Cell #:
Patient’s Insurance: Policy# Group#
Subscriber if different from patient: DOB:
Authorization Information if required* (e.g. #, # visits allowed, expiration date):
* If Authorization is required, requesting physician/clinic must complete prior to appointment.
Please check affected eye:
← Right eye
← Left Eye
← Both Eyes
Please check patient’s symptoms and add additional information if necessary:
← Decreased vision ___________________________________________________________________
← Visual Loss________________________________________________________________________
← Visual field loss_____________________________________________________________________
← Double Vision ______________________________________________________________________
← Ptosis_____________________________________________________________________________
← Anisocoria_________________________________________________________________________
← Other_______________________________________________________________________________________________________________________________________________________________
Presumptive Diagnosis:
← Optic Neuritis_______________________________________________________________________
← Optic nerve swelling (unilateral)_________________________________________________________
← Papilledema________________________________________________________________________
← Optic atrophy_______________________________________________________________________
← Thyroid eye disease__________________________________________________________________
← Cranial nerve palsy (3rd, 4th, or 6th)_______________________________________________________
← Brain mass_________________________________________________________________________
← Multiple Sclerosis____________________________________________________________________
← Myasthenia Gravis___________________________________________________________________
← Strabismus_________________________________________________________________________
← Other_____________________________________________________________________________
Additional Information: _________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
Onset/Duration: ______Days ______Weeks ______Months ___________Years________
Required Documents: We request that you send all information pertaining to referral, please mark included:
1. Medical Records (include last 3 visits) Included Not available
2. Imaging, included MRI or CT
(both report and CD/DVD required) Included Not available
3. Visual Fields Included Not available
4. Lab Results Included Not available
Other documents: _______________________________________________________________________
Urgent: Name of the Provider you spoke with:_______________________
If Urgent a call to referring physician’s office must be made physician to physician.
□ Routine: ________Next Avail______Days ______Weeks ______Months ___________Other
Requesting Physician Information
Name: Phone: Fax#
Address: City: State:
Contact Person: Ext.#:
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