Get Referral Form - Bochner Eye Institute

This guide provides a step-by-step approach to completing the Referral Form for the Bochner Eye Institute online. Whether you are a patient or a referring doctor, this process is designed to be straightforward and user-friendly.

Follow the steps to successfully complete the form.

1. Press the 'Get Form' button to access the Referral Form and open it in your preferred editor.
2. Fill in the patient information section, including the last name, first name, middle initial, city, province/state, zip/postal code, address, phone numbers for daytime and evening contact, occupation, email, birthdate, and sex. Ensure each field is completed accurately.
3. Indicate the physician to whom the patient is being referred in the 'Referred to' section.
4. Complete the scheduling information by providing the desired date for the procedure and selecting which procedure is needed.
5. In the pre-procedure assessment section, fill out the unaided visual acuity, manifest refraction, cycloplegic refraction, keratometry details, intraocular pressure (IOP), and add any necessary comments regarding eye health.
6. Document the contact lens usage and pupil diameter observations. Note any abnormalities and add comments as necessary.
7. In the medical history section, include any relevant medical conditions, current medications, previous eye surgeries, diseases, injuries, and allergic reactions.
8. Choose the recommended procedure from the options given and indicate any preferences regarding monovision. Provide a desired outcome for each eye if applicable.
9. Complete the referring doctor section by entering the doctor's name, location, email, phone, fax, and adding their signature. Ensure the date is filled in as well.
10. After completing the form, save your changes, and you can download, print, or share the form as needed.

Complete your documents online today for a seamless experience.