Download Diabetic Eye Examination Report

FAX COVER SHEET
for
Diabetic Eye Examination Report
Patient Name_____________________________________DOB_______________________
Date of eye exam: _________________________
Thank you for seeing our patient and being a valuable provider of
their Diabetic Eye Care.
Please return completed form to:
Crozer Medical Associates
1553 Chester Pike Suite 201
Crum Lynne, PA 19022
PCP ______________________________
Office: (610) 499-7180
Fax: (610) 876-0859
I give my permission to release this information to my PCP listed above.
____________________________
Signature
__________________
Date
Your patient was examined in our office on the above date and found to have the following
findings in regard to the retinal examination.
______No diabetic retinopathy,
OD_______OS______
______Background diabetic retinopathy,
OD_______OS______
______Proliferative diabetic retinopathy,
OD_______OS______
______Other Ocular Conditions:
Examiner’s Name _______________________________________________________________
Examiner’s Address _____________________________________________________________
Examiner’s Telephone Number ____________________________________________________
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error, Please notify me immediately at the telephone number indicated above and either destroy these documents or return the original by mail.
Thank you