COLLABORATING WITH YOU

Whether you are considering sending your patients with a referral, co-managing their pre- and post-op experience, visiting one of our clinics to watch surgery and learn from our experience, or applying for a fellowship, we consider it one of our greatest privileges to collaborate with doctors around the world to improve vision. Patients around the world benefit from our educational sharing, and we hope that as a doctor you will take full advantage of our resources.

Refractive Surgery Assessment & Referral

Refractive Surgery Assesment & Referral Form

*Preferred Gimbel Eye Centre location?

Patient Name: *First Name:	*Last Name:
*Email Address:	Sex:
DOB (mm/dd/YY):	Address:
City:	Province/State:
Postal/Zip:	Telephone (res):
Telephone (bus):	Telephone (cell):
Name of Doctor Assessing:
Telephone:	City:

Patient History
Ocular History (e.g., Injury, Amblyopia, Previous Eye Surgery Dry Eye, Motivation for surgery, etc.):
Medical History:

Please Check:	Diabetes	Vascular Disease	Ocular Herpes Simplex/Zoster	Pregnancy/Nursing
	Collagen	Auto Immune	Other(please specify):

List Medications, include Imitrex® (migraine), Accutane® (acne), Amiodarone® (cardiac anti-arrhythmic) &/or Flomax® (urinary flow):
Ocular:		Systemic:

Current Spectacles

OD:

OS:

Prism:	Eye Dominance:
Current Contact Lens Rx	OD:	OS:
If contact lenses are worn, indicate:	Soft RGP Monovision Simulated

Refraction Date:		OD	OS
Vertex Distance:		20/	20/
Keratometry Readings
Pupil Size (Diameter in dim illumination)		mm	mm
Best Corrected Visual Acuity		mm	mm
Anterior Segment
Posterior Segment
	C/D (Cup-to-disc ratio)
	Macula
	Periphery
Pachymetry

Monovision Discussed

Comments:

Vision Correction Options

Gimbel Eye Centre has a variety of vision correction options. Read more, and be sure to visit our library of animated videos.

Are You a Candidate?

Have you been considering vision correction? Read our candidate guidelines.

FAQ

Do you have questions? Read here for answers to the most commonly asked questions about eye surgery.

Events

Gimbel Eye Centre routinely offers seminars and workshops for doctors. Visit our Events page to learn more.

Gimbel Eye Foundation

The Gimbel Eye Foundation was established in 1984, to raise the level of patient care in Canada and around the world. Learn more