Referral Form - West Coast Glaucoma

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 of Referral request*

Date filling out this consult request

Patient's information

Patient LAST NAME*

Patient FIRST NAME*

Patient MIDDLE NAME

PHN*

(enter 0000 if no BC Health care card)

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of BIrth*

Patient's preferred contact method

Phone

e-mail

Patient's primary phone number*

Type of phone line*

Cell

Home

Office

Type of phone line for preferred phone

Patient's alternate phone number

Type of phone line (alt)

Cell

Home

Office

Type of phone line for alternate number

Patient's e-mail address

Enter Email Confirm Email

Referring Dr's information

Referring Dr LAST NAME*

Referring Dr FIRST NAME

Referring Dr MSP Billing #*

Referring Dr Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Reason for referral

New or repeat consult

Reason for referral

Glaucoma

Diabetic eye exam

Cataract

Flashes/Floaters

Red eye

Pain

Decreased vision

select all that apply

Reason for referral (other)

Objective exam

Visual Acuity OD (with correction)

Visual Acuity OS (with correction)

MRx OD

MRx OS

Date of IOP #1

Time of IOP #1

IOP #1 OD [mmHg]

IOP #1 OS [mmHg]

Date of IOP #2

Time of IOP #2

IOP #2 OD [mmHg]

IOP #2 OS [mmHg]

c/d ratio OD

c/d ratio OS

Additional Clinical Notes

History, meds, surgeries, questions

File upload

Drop files here or

Max. file size: 20 MB.

(support documents eg VF, OCT, photos, chart notes)

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