REFERRING PHYSICIAN
Practice Name
Phone Number:
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)
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Fax Number:
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)
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Provider Name
NPI/Medicaid Number
Date:
PATIENT INFORMATION
Patient Name:
First
Last
Phone:
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)
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Date of Birth:
E-mail
Insurance Plan
Appointment Date Requested:
Location Requested
Please select...
Jupiter
West Palm Beach
Port St. Lucie
Lake Worth
REASON FOR REFERRAL
Decreased Vision/Amblyopia (368.0)
Strabismus/Eye Movement Abnormality:
Eso- inwards (378.0)
Exo- outwards (378.10)
Other Eye muscle problem (378.87)
Eye Pain (379.91)
Trauma (921.1)
Red Eye [conjunctivitis] (372.0)
Foreign Body (930.1)
Tearing [tear duct obstruction/problem] (375.55)
Lid Droop (374.31)
Visual Disturbance (368.10)
Headaches (784.0)
Blinking (367.53)
Poor red reflex (930.1)
Other
Comments/Other Pertinent Findings:
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