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Get OHSU Casey Eye Institute Consultation Request Form 2019-2024

Name: Address: Date of birth: Phone number (h): Phone number (w): Patient Insurance Information: Needs to be seen: Urgent (within 48 hrs) For: Evaluation Next Available Treatment Other, please explain: Evaluation and Treatment Patient Preliminary Diagnosis, Symptoms or Signs: This section should also be used to list any tests or procedures performed for this patient presenting problems. Please communicate findings to me by: Fax Requesting Physician/Provider name and NPI number.

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  • TEL
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