ConsultationPatient Information Name Gender MaleFemale DOB (yy/mm/dd) Home Phone Other Address Unit # City Postal Code Healthcard Version Code Email Reason for Referral Cataracts (OHP Surgery) Premium IOL Undecided Narrow Angles Glaucoma iabetic Check Wet AMD CRVO/BRVO Dry Eye/CODEC Other: MEDICATION*OD (RIGHT)OS (LEFT)Best Corrected VARefractionIOPCCT Comments Referring Doctor's Name Provider # Phone Fax Back # Family Doctor Preferred Consult Location: Ajax 145 Kingston Road E. Unit #3 Brampton 350 Rutherford Road South Suite 300 Plaza II Midtown 1849 Yonge Street Suite 705 Newmarket 130 Mulock Drive Unit 3 Roncesvalles 2238 Dundas Street W Suite 308 Scarborough 2855 Markham Road Suite 408 Vaughan 9135 Keele Street Unit A5