Cataract Referral
?KERATOCONUS/CORNEAL CROSS Sightline Ophthalmic AssociatesLINKING CONSULT REQUEST Phone 724-933-5588 ? Fax 724-933-6051 _________________________________________________________________________________________________PATIENT NAME ______________________________ □ I have scheduled an appointment for this patient on: DATE OF BIRTH _____________________________ _________________________________________REFERRING DOCTOR _____________________________ □ I would like Sightline to call this patient to schedule:DATE OF EXAM ___________________________________ PATIENT PHONE __________________________ _________________________________________________________________________________________________REASON FOR REFERRAL:CURRENT OCULAR SYMPTOMS:EYE HEALTH HISTORY (And other pertinent health Hx):? Pt already diagnosed with keratoconus Date of diagnosis:__________? Pt suspect of having keratoconus? Pt had laser vision correction Date of laser surgery:__________Pt wears contact lenses: ? soft ? RGP ? Scleral ? Spectacle or no correctionCURRENT REFRACTION:OD_______________________________________ 20/_______ OS_______________________________________ 20/_______ PREVIOUS REFRACTION DATE: __________OD_______________________________________ 20/_______OS_______________________________________ 20/_______ PERTINENT SLIT LAMP FINDINGS:? Scarring? Striae PERTINENT FUNDUS FINDINGS: DIAGNOSIS:REQUESTED CARE: ? EVALUATION/TOPOGRAPHY ONLY ? EVALUATION AND CROSS LINKING IF INDICATED ? TOPOGRAPHY ONLYIF PATIENT REQUIRES CONTACT LENSES, DO YOU FIT RGP AND SCLERAL CONTACTS? ? YES ? NO______ Report Faxed to Sightline Signature _____________________________________ ................
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