Diagnostic Services Request - odpcli.com

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Revised 2017-7 Fax to (509) 735-6868 or mail to PCLI 6695 W Rio Grande Avenue, Kennewick, WA 99336 OD OS Diagnostic Services Request F o r c a r e a va i la b l e a t o u r K en n e wi c k of fi ce REFERRING DOCTOR PATIENT INFORMATION Name ________________________________________ _____________ Name ________________________________________ _____________ Address ________________________________________ ___________ Address ________________________________________ ___________ ________________________________________ __________________ ________________________________________ __________________ Phone (_____) ________________________________________ ______ Phone: Hm (_____) ________________ Wk (_____) _______________ Date of Referral ________________________________________ _____ Date of Birth ________________________________________ ________ ASSESSMENT Working Diagnosis ________________________________________ ______________________________ ICD-10 Code (required) _______________ Services REQUESTED OD OS OU Anterior segment photos Can patient be safely dilated with tropicamide and phenylephrine?

Revised 2017-7 Fax to (509) 735-6868 or mail to PCLI 6695 W Rio Grande Avenue, Kennewick, WA 99336 OD OS Diagnostic Services Request For care available at …

  Services, Request, Diagnostics, Diagnostic services request