Get the free Retinal Eye Screening Referral Form - Central West Self ... - cwselfmanagement

Diabetes Education Center OTN Retinal Screening Program Diabetes Education Center OTN Retinal Screening Program Brampton Civic Hospital Center for Complex Diabetes Care 3022250 Covered Drive East

How to fill out retinal eye screening referral

How to fill out retinal eye screening referral:

1. Obtain the necessary forms: Start by obtaining the retinal eye screening referral form from your healthcare provider or optometrist. This form may also be available online for download.
2. Fill in personal information: Begin by filling in your personal information such as your full name, date of birth, and contact information. Make sure to double-check the accuracy of these details to prevent any potential errors.
3. Provide relevant medical history: In the referral form, there will likely be a section asking for your medical history. Fill in any relevant information regarding previous eye conditions, surgeries, or any medications you are currently taking.
4. Include the reason for referral: Clearly state the reason why you are being referred for retinal eye screening. This may be due to symptoms you are experiencing, a family history of eye conditions, or as a routine screening recommended by your healthcare provider.
5. Indicate the referring healthcare professional: Write down the name and contact details of the healthcare professional who is referring you for the retinal eye screening. This could be your optometrist, ophthalmologist, or general practitioner.
6. Note any additional instructions: If there are any specific instructions or requirements for the screening, ensure that you include them on the referral form. This could include fasting requirements, necessary preparation, or any specific tests that need to be conducted.

Who needs retinal eye screening referral:

1. Individuals with diabetes: Diabetic patients are at a higher risk of developing retinal conditions, such as diabetic retinopathy. Regular retinal eye screening is essential to detect any abnormalities and treat them promptly.
2. Those with a family history of eye diseases: If you have a close relative who has been diagnosed with an eye condition, it is advisable to undergo retinal eye screening. Some conditions, like glaucoma or macular degeneration, have a genetic component that increases the risk for individuals with a family history.
3. Patients with high blood pressure or other systemic conditions: Certain systemic conditions, including high blood pressure, can have an impact on the health of your eyes. Regular retinal eye screening can help identify any early signs of damage to the blood vessels in the retina.
4. Individuals over a certain age: As individuals age, the risk of developing certain eye conditions, such as cataracts or age-related macular degeneration, increases. Retinal eye screening is recommended for older adults to monitor and address any potential issues.
5. People experiencing visual symptoms: If you are experiencing any visual symptoms such as blurred vision, floaters, or sudden changes in eyesight, seeking a retinal eye screening referral is crucial. This will help identify any underlying eye conditions that may be causing these symptoms.

Remember, it is always best to consult with your healthcare provider or optometrist to determine if you need a retinal eye screening referral based on your specific circumstances.

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