Transcription of Diagnostic Services Request - odpcli.com
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Diagnostic Services Request - odpcli.com
Revised 2017-7 Fax to (360) 698-5231 or mail to PCLI 9598 Mickelberry Road NW, Silverdale, WA 98383 Diagnostic Services Request F o r c a r e a va i la b l e a t o u r S i l ve r d a l e off ic e OD OS 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 B-scan ultrasonography Can patient be safely dilated with tropicamide and phenylephrine? Topography/Pentacam Yes Pachymetry If not, please explain. _____ Visual field _____ Test strategy requested _____ Optical Coherence Tomography (OCT): If visual field or OCT is requested, please provide refraction.
Revised 2017-7 Fax to (360) 698-5231 or mail to PCLI 9598 Mickelberry Road NW, Silverdale, WA 98383 Diagnostic Services Request For …
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