Patient Name:
MEDICAL
PHOTOGRAPHY
AND IMAGING
ORDERS
Date of Birth:
*Bold fields are mandatory*
Office: 212-979-4381
Reset Form
310 East 14th Street
8TH FLOOR NORTH BLDG.
Appointments: 212-614-8301
Type:
Angiography: ICG Spectralis
Movie
Stills Early Run:
R
L
Dx Code:
R
L
Dx Code:
*Requires dilation order- pg2
Early Run:
Angiography: ICG Standard
R
L
Dx Code:
L
B
Dx Code:
*Requires dilation order- pg2
Site:
Corneal Topography
R
Electrophysiology: EOG
Dx Code:
*Requires dilation order- pg2
Electrophysiology: Full Field ERG
Dx Code:
*Requires dilation order- pg2
Electrophysiology: Multifocal ERG
Dx Code:
*Requires dilation order- pg2
Electrophysiology: VEP
Dx Code:
External Photography
Dx Code:
Fluorescein Angiography: Spectralis Type:
Movie
Stills Early Run:
*Requires dilation order- pg2
Early Run:
R
L
Dx Code:
Fluorescein Angiography: Wide Field Early Run:
R
L
Dx Code:
Fluorescein Angiography: Standard
*Requires dilation order- pg2
*Requires dilation order- pg2
Fundus: Standard
Site:
R
L
B
Dx Code:
Site:
R
L
B
Dx Code:
Site:
R
L
B
Dx Code:
Site:
R
L
B
Dx Code:
Site:
R
L
B
Dx Code:
*Requires dilation order- pg2
Fundus: Auto FA Photography
*Requires dilation order- pg2
Fundus: Red Free Photography
*Requires dilation order- pg2
Fundus: Stereo Disc Photography
*Requires dilation order- pg2
Fundus: Wide Field Photography
*Requires dilation order- pg2
IOL Master: A Constant:
Target Refraction:
Preferred IOL Calculation Formula:
Right Eye Status:
SRK/T
Phakic
Aphakic
Silicone Filled Eye
Left Eye Status:
Phakic
*RDC PHOTO ORDER*
RDC PHOTO ORDER
SRK II
Holladay
Pseudophakic Silicone
Silicone Filled Aphakic
Aphakic
Silicone Filled Eye
Dx Code:
Hoffer Q
Pseudophakic Acryl
N/A
Pseudophakic Silicone
Silicone Filled Aphakic
Haigis
Pseudophakic Acryl
N/A
**DILATION ORDERS AND
REQUIRED SIGNATURE ON PAGE 2**
pho.001a Form Fast 3/15
Page 1 of 2
MEDICAL
PHOTOGRAPHY
AND IMAGING
ORDERS
*Bold fields are mandatory*
Office: Telephone 212-979-4381
310 East 14th Street
8TH FLOOR NORTH BLDG.
Appointments: Telephone 212-614-8301
OCT: Anterior Segment
Site:
R
L
B
Dx Code:
OCT: EDI
*Requires dilation order
Site:
R
L
B
Dx Code:
OCT: Microperimetry
*Requires dilation order
Site:
R
L
B
Dx Code:
OCT: Nerve Raster
Site:
R
L
B
Dx Code:
OCT: RNFL
Site:
R
L
B
Dx Code:
Site:
R
L
B
Dx Code:
*Gonioscopy Requires Proparacaine order Site:
R
L
B
Dx Code:
Site:
R
L
B
Dx Code:
Ultrasonography: A Scan *Requires Proparacaine order Site:
R
L
B
Dx Code:
OCT: Macula
Slit Lamp
*Requires dilation order
Specular Microscopy
*Requires Proparacaine order
Ultrasonography: B Scan
Right Clock Position:
Site:
Ultrasonography: UBM
*Requires
Proparacaine order
R
L
Left Clock Position:
B
Dx Code:
Right Clock Position:
Light Adapt
Site:
R
Left Clock Position:
Dark Adapt
L
B
Pre - Procedure Dilation Medications:
Dx Code:
Notify MD if:
1 (One) drop Proparacaine 0.5% 1X
OD
OS
OU
1 (One) drop Tropicanamide 1% 1X
OD
OS
OU
1 (One) drop Phenylephrine 2.5% 1X
OD
OS
OU
i. Pulse below 60 BPM or above 100 BPM
ii. Any bruising, swelling, exudate or
possible trauma to either eye
iii. Intraocular pressure above 30 mm
iv. Allergies to ordered dilation medications
v. Potential for interaction with patient
current medication regime and ordered
dilation medications
Instructions for procedure:
MD Name
pho.001b Form Fast 3/15
MD Signature
Date
Time
Page 2 of 2