Cataract

Cataract Surgery

This form referral form is intended for referrals to a Cataract Surgery service

Formatting and style is intended to be consistent with other provincially standardized forms to reduce cognitive loads

The number of mandatory fields is limited to reduce administrative burdens

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

This form is dynamic - selecting an option may reveal additional/nested fields

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

He/Him

She/Her

They/Them

Other

Preferred name

Preferred language:

English

French

Other

Best method of contact:

Mobile

Home

Business

Email

Alternate contact

Unsafe contact persons (do not speak with)

Accessibility concerns or disability

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Send copies of reports to additional providers

Referral Source

Please specify:*

Optometrist/Ophthalmologist

Primary Care

Cataract referrals are ideally submitted by an optometrist who has recently completed a comprehensive eye exam, to ensure other eye diseases are assessed and ruled out. However, a primary care provider can refer a patient with an attached optometry / opthalmology report completed in the last 3-6 months.

Clinical Optometry / Opthalmology Report attached *

Referral Information

The Cataract Central Intake does not accept urgent referrals. For urgent cases, contact your local ophthalmologist directly.

Affected Eye(s):*

Right Eye (OD)

Left Eye (OS)

Both Eyes (OU)

Details or Additional Comments:

Preferred Surgeon or Location

All patients will be triaged to the shortest wait time unless a preferred surgeon or location is entered.

Preferred surgeon or location

Patient willing to travel for shorter wait time

Other considerations:

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Ontario Health & Amplify Care

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Notes

Overview

This form referral form is intended for referrals to a Cataract Surgery service
Formatting and style is intended to be consistent with other provincially standardized forms to reduce cognitive loads
The number of mandatory fields is limited to reduce administrative burdens

X

Notes

Patient Information

These fields are auto-populated when referral is initiated from an integrated Electronic Medical Record (EMR) or Hospital Information System (HIS).

X

Notes

Additional Patient Information

This section is optional for referrers to complete
Referring providers should use their judgement to determine if any of these fields should be completed. Some fields will auto-complete if launched from an integrated EMR or HIS.

X

Notes

Referral Source

Selecting the referral source will change the display on the form.
During setup, the Central Intake will decides if they will accept referrals from primary care.
Selecting "Primary Care" as the Referral Source will EITHER prompt the referrer to attach a recent Clinical Optometry Report OR inform the referrer that they cannot refer the central intake, depending on the Central Intake's decision.
Selecting "Optometrist/Ophthalmologist" will prompt users to provide key clinical details in the Patient Health History section below as an attachment, or in the form itself.

X

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

X

Brief Description

This mandatory field is meant to describe the relevant patient information, which may include the current history, management, investigations, or expectations of the referral

X

Notes

Preferred Consultant or Location

This section will only be displayed for group practices or central intakes

X

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.

X