DILATED RETINAL EYE EXAM COMMUNICATION FORM. This form is to document dilated eye exam results. Place form directly in the person's medical record.
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How to fill out the Dilated Retinal Eye Exam Communication Form - Dhs Wisconsin online
Completing the Dilated Retinal Eye Exam Communication Form is essential for documenting eye exam results and ensuring proper medical records. This guide will provide you with clear instructions to easily navigate the form online.
Follow the steps to complete the Dilated Retinal Eye Exam Communication Form effectively.
- Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Patient: Fill out your name, date of birth, phone number, and the names of your primary care clinician and eye care specialist. Ensure this form or a copy is returned to your primary care clinician after your yearly dilated eye exam. The necessary fields include: Name, Date of Birth, Phone Number, Primary Care Clinician's Name, Eye Care Specialist's Name, along with their respective clinic addresses and contact information.
- Eye Care Specialist: After completing the eye exam, fill in the date of the eye exam and indicate if the eyes were dilated for the exam by selecting 'Yes' or 'No'. Provide detailed findings from the retinal examination such as whether there was diabetic retinopathy and any follow-up recommendations. Make sure to sign and date this section.
- Primary Care Clinician: After receiving the form back, ensure that the Dilated Retinal Eye Exam Communication Form is placed in the patient's medical record for future reference.
- Once all fields are filled out, save your changes. You may also download, print, or share the completed document as needed for your records.
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