Your Partner in Health Care Quality Diabetic Dilated Eye Exam Fax Back Report Patient Name: Birth Date: Primary Care Physician: Fax # Findings/Impressions: NPDR Non Proliferative Diabetic Retinopathy.
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How to fill out the Examfax online
Filling out the Examfax is an essential process for providing detailed information regarding diabetic eye examinations. This guide will walk you through each section of the form, ensuring that all required information is accurately captured.
Follow the steps to complete the Examfax form effectively.
- Press the ‘Get Form’ button to obtain the Examfax and open it in the editor.
- In the 'Patient Name' section, enter the full name of the patient receiving the exam.
- Next, fill in the 'Birth Date' field with the patient’s date of birth in the appropriate format.
- Under 'Primary Care Physician,' provide the name of the patient’s primary care doctor.
- In the 'Fax #' section, enter the fax number where the report should be sent.
- In the 'Findings/Impressions' section, mark the relevant options that apply to the patient’s condition, including NPDR, PDR, or other findings.
- For 'Recommendations,' outline any suggested actions as per your assessment; check off relevant options.
- Complete the 'Eye Care Specialist Signature' and 'Date' sections to certify the findings.
- Once all sections are filled out, you can save changes, download, print, or share the form as needed.
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