CO-MANAGEMENT SERVICES
TYPE OF CONSULTATION



Attn: SURGERY COORDINATOR
Please fax form to :
(503) 386-1377
Date
REFERRING PROVIDER INFORMATION
Referral Submitted by
Clinic Name
Ordering Provider


PATIENT INFORMATION
Name
DOB
Referring Doctor
Date of Exam

CLINICAL INFORMATION ( Please provide any information available )

Manifest Refraction
OD ×
OS ×
Add
Old Rx
OD ×
OS ×
Add
Keratometry
OD - ×
OS - ×
Pachymetry
OD
OS
Tonometry
OD
OS

FOR CATARACTS PLEASE INDICATE ANY IOL PREFERENCE/INTEREST

655 Medical Center Dr NE       |       Salem, Oregon 97301       |     503.581.5287       |         Fax 503.386.1377       |       mceyeclinic.com