SouthEast Eye Specialists PLLC

Available Forms

Glaucoma Reporting/Update Form Post-op - SLT Post-op - Yag Capsulotomy Post-op - Yag PI

Glaucoma Reporting/Update Form

Glaucoma Reporting-Information Sharing Form

Please use this form when co-managing Glaucoma patients with SouthEast Eye Specialists. Information such as vision changes, IOP, VFs, and OCTs can be conveyed securely. This is not intended to be used for initial patient consultation.

Patient & Consulting Doctor Information

Patient Name: *

Date of Birth: *

Consulting Doctor: *

Office location (if multiple):

Glaucoma Information:

Exam date:

Best Corrected Distance VA OD: 20/

Best Corrected Distance VA OS: 20/

IOP OD (mmHg): *

IOP OS (mmHg): *

Time: *

IOP Method: *

Was Visual Field performed? *

Yes

If yes, please attach/fax to SEES

Was Optic Nerve OCT/HRT performed? *

Yes

If yes, please attach/fax to SEES

Eye Medications

Patient eye medications and dosing schedule

Additional Information

Other pertinent information to convey to SEES doctor:

By entering my initials below and submitting this form, I am verifying that the information in this post-op report is accurate and true as of the date of the exam.

Doctor's Initials: *

* Required field