Referral Form

"*" indicates required fields

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.

YYYY slash MM slash DD
Date filling out this consult request

Patient's information

(enter 0000 if no BC Health care card)
Patient Address
YYYY slash MM slash DD
Patient's preferred contact method
Type of phone line*
Type of phone line for preferred phone
Type of phone line (alt)
Type of phone line for alternate number
Patient's e-mail address

Referring Dr's information

Referring Dr Address

Reason for referral

Reason for referral
select all that apply

Objective exam

MM slash DD slash YYYY
Time of IOP #1
:
MM slash DD slash YYYY
Time of IOP #2
:
History, meds, surgeries, questions
Drop files here or
Max. file size: 20 MB.
    (support documents eg VF, OCT, photos, chart notes)