ocularis - Montreal retina Institute

Clinique de l’oeil
OCULARIS
Eye Clinic
FORMULAIRE DE CONSULTATION
REFERRAL FORM
REQUÉRANT / REFERRING DOCTOR:
Dr. ________________________________________
No. Permis: _________________
Date: __________________
Établissement & Adresse/Address: ______________________________________________________________________
Tél: _____________________________________
Télécopieur / Fax: _________________________________
RENSEIGNEMENTS CLINIQUES / PATIENT INFORMATION:

NOM/NAME: __________________________________________ TÉL: _____________________________

 URGENT

MOTIFS DE LA DEMANDE / REASON FOR REFERRAL:
 DMLA/AMD  DIABÈTE
 OCCLUSION VASCULAIRE
 DÉCOLLEMENT/DETACHMENT
 MER/ERM
 TROU MACULAIRE/MACULAR HOLE
 AUTRE/OTHER
 SEMI-URGENT
 NON-URGENT
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

EXAMEN/EXAM
AV/VA: __________ OD __________ OS
PIO/IOP: _____ mmHg OD _____ mmHg OS
RÉFRACTION: ______________________________ OD
FOND D’OEIL/:
FUNDUS
OD
______________________________OS
OS
VEUILLEZ CHOISIR LA CLINIQUE / PLEASE INDICATE CLINIC:


Clinique de l’œil OCULARIS
OCULARIS Eye Clinic
4120, Ste. Catherine O.
Westmount, QC H3Z 1P4
Tél: (514) 285-8808
Fax: (514) 285-9191
L’INSTITUT DE LA RETINE DE MONTREAL
MONTREAL RETINA INSTITUTE
e
4120, Ste. Catherine O., 2 étage
Westmount, QC H3Z 1P4
Tél: (514) 285-8838
Fax: (514) 285-8897
VEUILLEZ COCHER LE MÉDECIN CONSULTANT / PLEASE INDICATE PHYSICIAN:
OCULARIS:
MRI/IRM :
 Dr. A. Hafez
 Dr. J. Chen
 Dr. S. Huang
 Dr. J. Galic
 Dr. M. Al Otaibi
 Dr. M. Quigley
 Dr. M. Sébag