Optometrist Request for Corneal Topography Pentacam examination by wku19297

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									Optometrist Request for Corneal Topography or Pentacam examination




Optometrist name:             _____________________________________________


Patient name:                 _____________________________________________


Address:                      _____________________________________________


                              _____________________________________________


Date:                         _____________________________________________


Request:   mark with an “x”


Corneal Topography                        
                                                       (Please select one only)



Corneal Tomography (Pentacam)             




                Dedicated Optometry Telephone Number 01 2935977
                          Facsimile Number 01 2935978

								
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