Referral Form

  • This form is for eye care professionals and Family Doctors to complete on-line to refer a patient to see Dr Schertzer. There is also a printable referral form that can be faxed if that is easier for your office. Please be sure to submit 03333 referral code to MSP to Dr Robert Schertzer MSP #26035.

    We triage requests throughout the day; calling does not get your patient in more quickly unless it’s a true emergency.

    We will fax the appt. information to you. Patients will receive up to 3 appointments: a consult, visual field testing, and imaging, depending on the diagnosis.

    Please tell patients that the appt can take up to 2 hours. They should bring their preferred glasses and ALL medications, including eye drops.

    The waiting room size is limited; please ask patients to bring no more than one support person to the visit.

  • Date Format: YYYY slash MM slash DD
    Date filling out this consult request
  • Patient's information

  • (enter 0000 if no BC Health care card)
  • Date Format: YYYY slash MM slash DD
    Type of phone line for preferred phone
    Type of phone line for alternate number
  • Referring Dr's information

  • Reason for referral

    select all that apply
  • Objective exam

  • Date Format: MM slash DD slash YYYY
  • :
  • Date Format: MM slash DD slash YYYY
  • :
  • History, meds, surgeries, questions
  • Drop files here or
    (support documents eg VF, OCT, photos, chart notes)