Cataract Surgery Central Intake
This is a draft standard eReferral form for Cataract Surgery Central Intake.
Please provide your feedback in the form on the right-hand side
The form is designed to be viewed on a computer.
For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.
Patient Information
Surname:
First:
DOB:
Gender:
HN:
Mobile #:
Home #:
Business #:
Email:
Address:
* Indicates a required field
*Optional* Additional Patient Information
Sex assigned at birth:
Preferred pronouns:
Preferred language:
Best Method of Contact:
Referral Source
Please specify:*
Referral Information
The Cataract Central Intake does not accept urgent referrals. For urgent cases, contact your local ophthalmologist directly.
Please Select Affected Eye(s):*
Would the patient be interested in a Specialty IOL Implant?*
Details:*
Preferred Surgeon or Location
All patients will be triaged to the shortest wait time unless a preferred surgeon or location is entered.
+ Add Attachments
Referrer's Information
Site Name:
Address:
City:
Province:
Postal Code:
Phone:
Fax:
Billing #:
Professional ID:
Signed:
Role:
Notes
Notes
Notes
Notes
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Ontario Health & eHealth Centre of Excellence