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 of Referral request*
YYYY slash MM slash DD

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*
YYYY slash MM slash DD
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
Email
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
MM slash DD slash YYYY
Time of IOP #1

: Hours

Minutes
IOP #1 OD [mmHg]
IOP #1 OS [mmHg]
Date of IOP #2
MM slash DD slash YYYY
Time of IOP #2

: Hours

Minutes
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
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Max. file size: 20 MB.
(support documents eg VF, OCT, photos, chart notes)
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Referral Form

Patient's information

Referring Dr's information

Reason for referral

Objective exam