Transcription of Diagnostic Services Request - odpcli.com
1 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.
2 Angle analysis OD _____ 20/ _____ Corneal analysis OS _____ 20/ _____ Macular analysis 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. _____ _____ _____ _____
