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BEOS - Patient Self-Referral

Patient's Name

*

Patient's Health Card #

*

Patient's Date of Birth

*

Patient's Primary Phone #

*

Patient's Email Address

*

Optometrist Name

*

Family Physician Name

*

Specific procedure requested

*

Specific procedure requested

Eyelid Surgery (Blepharoplasty)

Ptosis Surgery (Droopy Eyelid)

Chalazion Removal

Cyst / Mole Removal

Skin Tag / Papilloma Removal

Cosmetic Botox Injection

Clear Lens Exchange (Refractive Surgery)

Cataract Surgery with Premium Lens

Please describe your concern in further detail

*

Have you seen another ophthalmologist in the past?

*

Have you seen another ophthalmologist in the past?

Yes

No

If yes, please provide further details below

*

Please provide a photograph of the area of concern

*

Size limit: 10 MB