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BEOS/BLEC - Patient Self-Referral
Patient's Name
*
Patient's Health Card #
*
Patient's Date of Birth
*
Patient's Primary Phone #
*
Patient's Email Address
*
Patient's Address
*
Optometrist Name
*
Family Physician Name
*
Specific procedure requested
*
Eyelid Surgery (Blepharoplasty, Blephroptosis)
Chalazion Removal
Cyst / Mole Removal
Skin Tag / Papilloma Removal
Xanthelasma Removal
Cosmetic Botox Injection
Clear Lens Exchange (Refractive Surgery)
Please describe your concern in further detail
*
Have you seen another ophthalmologist or had any eye surgery in the past?
*
Yes
No
If yes, please provide further details below
*
Please provide a photograph of the area of concern
*
Click to choose a file or drag here
Accepts .jpg, .jpeg, .png files
Size limit: 10 MB
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