Transcription of Diagnostic Services Request - odpcli.com
1 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? Topography/Pentacam Yes Disc photos If not, please explain. _____ Fundus photos _____ HRT optic nerve analysis Pachymetry Specular microscopy endothelial study Visual field Test strategy requested _____ Optical Coherence Tomography (OCT): If fundus photos, visual field, or OCT is requested, please provide Angle analysis refraction.
2 Corneal analysis OD _____ 20/ _____ Macular analysis OS _____ 20/ _____ Optic nerve head analysis Retinal nerve fiber layer Unless requested, these tests will be provided without interpretation. Do you want us to interpret test results for you? Yes AREAS OF INTEREST If OCT or photos are requested, please indicate and/or comment on the areas of interest. _____ _____
