Patient Referral Form

Clinical Trial / Retina Scheduling Form

I recommend the following patient to be screened for a clinical trial at Erie Retina Research.
Date of Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Format: (000) 000-0000.
E-mail Address
example@example.com
BCVA Measurement RIGHT EYE - OD
BCVA Measurement LEFT EYE - OS
Main Diagnosis
Specific Trial Referral or Suggestion?
General Comments
Information submitted to Erie Retina Research by:

First NameLast Name
Referring Practice Name or Physician
Upload any images or files here:

Cancelof
Rapid Screen Appointment Picker. Date is not guaranteed however our team will do our best to accommodate! Erie Retina Research will call patient to confirm.
PRIVACY NOTICE
The health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use your health information for purposes of treatment, payment and health care operations. Under HIPAA, you have the right to Request restrictions on how we use or disclose your health information in certain circumstances, including for treatment, payment or health care operations. We do not have to agree to your request unless you request restriction on disclosures to a health plan for purposes of payment or healthcare operations, and the health information relates to an item or service for which you, or another person on your behalf, have assumed full financial responsibility. If we do agree to your restrictions, we will be bound by our agreement except in limited circumstances, such as if there is an emergency.
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Clinical Trial / Retina Scheduling Form

PRIVACY NOTICE