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. 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.
2 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. _____ _____
