Referral Request | Pediatric Ophthalmology of Erie

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Date

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Patient First Name

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Patient Last Name

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Date of Birth

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Address

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Zip Code

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Insurance

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Ins. ID#

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Parent/Guardian name

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Phone #

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Alternate ph.#

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Parent/Guardian Email

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EYE (S) AFFECTED

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Eye Diagnosis/Suspected Diagnosis, please check all that apply:

Amblyopia (poor vision)

Eyelid Ptosis (droopy eyelid)

Strabismus (crossing/drifting)

Neoplasm/cyst/growth

Chalazion/Hordeolum/stye

Blocked tear duct/chronic discharge

Corneal clouding/Glaucoma

Conjunctivitis (pink/red eye)

Syndrome:

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Visual disturbance (blinking, squinting)

Please include eye symptoms

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Who sees the symptom?

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Spot Screening Results

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**Please include copy of Insurance cards and printed Spot screen results with appointment request if possible**

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Please contact me with appointment date and time

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Referring Doctors Name:

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Phone Number:

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I acknowledge that Pediatric Ophthalmology of Erie specializes in Pediatric Ophthalmology and Pediatric Optometry, we only treat medical eye conditions. We do not perform routine vision exams, (unless under the age of 5 and referred for failing a vision screening with documentation of the exam results) Appointment requests for routine exams will not be scheduled. We do not bill vision insurance for exams

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