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Dry Eye Referrals
Please submit your referral information below.
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Patient Details
Patient Name
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First
Last
Patient Date of Birth
(Required)
MM slash DD slash YYYY
Alberta Health Care No.
Patient Phone Number
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Email Address
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Email Address
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Referring Professional
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Main Concern
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Current Therapies
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Consent
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Patient has consented to sharing their information
By checking this box, you have confirmed the patient consented to sharing their information with The Eye Studio.
Patient History
Please select all that apply
Blepharitis
Contact Lens Use
Glaucoma Meds (describe below)
History of Eye Surgery
Internal or External Hordeolum
Rosacea
Sjogren’s Syndrome
Additional Comments/Information
Suggested Treatment(s)
Please select all that apply
(Required)
General referral for assessment and treatment
Intense Pulsed Light (IPL)
Radio Frequency (RF)
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