Ophthalmic Testing Request Form __________________________________________
Patient Name: _________________________ D.O.B.: Ancestry: __________ M F Diagnosis: _______________________ Date: _______________________
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Appt Time: _______________________
===================================== Retinal Nerve Fiber Analysis Rx (Distance) OD _______ OS _______ OD OS OU
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Pachymetry
OD OD OD Nasal 20◦
External
OS OS OS Temporal 45◦ OD
OU OU OU Central OS OU
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Blood Blow Analysis
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Digital Retinal Imaging
____________________________________________________________________________________ WHEN TESTING COMPLETED:
Patient to see the Doctor
Patient can checkout
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NOTE: RNFL ANALYSIS AND DIGITAL RETINAL IMAGING CANNOT BE PERFORMED ON THE SAME DAY UNLESS IT IS A PRIVATE PAY PATIENT