External Referral Form | Advanced Ocular Imaging Program

External Referral Form (non-果冻影院 physicians only) for 果冻影院 Advanced Ocular Imaging Program

To refer a patient to an AOIP imaging study complete the form and click submit. An AOIP staff member will receive the information and call the patient for scheduling.

Referring Physician Information

Physician Name *

Referring institution/clinic *

Referring physician email *

Password *

Upload HIPAA Document *

IRB Protocol

Patient Background

Patient first name *

Patient last name *

Date of last eye exam

Patient phone number *

Patient email

Parent first name

Parent last name

Gender * Female Male

Patient date of birth *

If other, enter diagnosis

Safe to dilate/adequate angle? * Yes No

Media opacities/lens status Clear +1NS +2NS +3NS Other

If other

Refraction Data Available? Yes No

Refraction date done

Notes about refraction

Imaging Request

Eye(s) to be imaged * OD OS OU

Describe region of interest. Please also comment on the research question and previous/desired ancillary testing.

Genetics Request

Has genetic analysis been done? * Yes No

If yes, briefly list results

Is genetic testing needed? * Yes No

Gene(s) of interest

You should see a Thank You message on the screen and receive an email confirmation of your form responses sent to the address listed in the physician email field above. If you do not see the Thank You message or receive the email confirmation, please contact (414) 955-AOIP (2647).

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