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Online Consultation Form
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Refractive Self-Test
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Online Consultation Form
Step
1
of
2
50%
Name
(Required)
First
Last
Patient Information
Date of Birth
(Required)
MM slash DD slash YYYY
Date of Exam
(Required)
MM slash DD slash YYYY
Phone
(Required)
Referring Doctor
Name
(Required)
First
Last
Practice
(Required)
NPI
(Required)
Email
(Required)
(Only used for confirmation of form submission)
Phone
(Required)
Fax
Location For Referral:
Bellingham
Renton
Sequim
Mount Vernon
Seattle
Smokey Point
Reason for Referral
Retina
Refractive
Yag Cap / PCO eval
Cataract (order pre-operative testing including corneal topography & biometry)
Oculoplastics
Strabismus
Cornea
Glaucoma
Other
Other
Team Preference
I have a Preferred Consulting Northwest Eye Surgeons Physician Team
I have no team preference
Preferred Consulting Northwest Eye Surgeons’ Physician Team.
(Please indicate Surgeon name) We will do our best to match your preferred referral request, and is not a guarantee. Patients may be directed to an alternate referring provider/team member due to scheduling needs.
Clinical findings/areas of concern:
Upload Chart Notes/Documents
Drop files here or
Select files
Max. file size: 150 MB.
Reason for referral
Glaucoma
Glaucoma Suspect
Narrow Angle
Has a matrix, humphrey or octopus visual field been performed in your office within the last six months?
Yes
No
Please attach any current chart notes, and last 3 or more years of visual fields and imaging
Max. file size: 150 MB.
Pretreatment and highest know pressures:OD
Pretreatment and highest know pressures:OS
Most recent IOP/range: OD
Most recent IOP/range: OS
Current glaucoma medications:
Pertinent history/risk factors/additional requests
Please Choose One
Consultation, second opinion: patient wishes to return to my office for glaucoma management.
Glaucoma consultation and management requested at NWES, comprehensive eye care at my office.
How do you want your patients co-managed? Choose one. If a selection is not made, your patient will be co-managed by NWES.
(Required)
Patient wishes to return to my office for post-op care.
Patient prefers NWES to manage surgical post-op care.
Pertinent history/risk factors/additional requests
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