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BEOS - eReferral Portal
Referring Physician
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Email Address
Phone Number
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Billing #
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Address
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Fax Number
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Patient's Name
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Patient's Address
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Patient's Health Card #
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City & Postal Code
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Patient's Date of Birth
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Patient's Primary Phone #
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Patient's Email Address
Family Physician Name
Does the patient have any accessibility needs?
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Primary Reason for Referral
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Primary Reason for Referral
Cataract Surgery
Oculoplastics
Glaucoma
Retina
Other
Please describe the concern in further detail
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Clinical Assessment - BCVA
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Clinical Assessment - IOP
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Clinical Assessment - Refraction
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Clinical Assessment - Notes
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Has the patient seen another ophthalmologist in the past?
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Has the patient seen another ophthalmologist in the past?
Yes
No
If yes, please provide further details below
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Please provide any relevant documents for this referral
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