Strabismus referral form

Pediatric-Cataract-Contacts
Eyemd.bz	Budning Eye Institute
Surgical - Medical

Andrew S. Budning MD FRCS(C)

305- 2300 Eglinton Avenue West

Mississauga, Ontario

phone: 905-820-5464

Fax: 905-569-2377

Strabismus referral form

Please book: this appointment: (Circle the appropriate time frame)

At your earliest convenience semi-urgently (<4 weeks) Urgently ________in days

Appointment date________________________________

Patient name:_____________________________________

Patient Address:

Birth date:_______________________________________

Referring Office Address and Tel/ Fax

Referring Doctor:____________________________________Health provider #____________

Diagnosis/ reason for referral

Relevant history, and allergies:

Eye medications:_________________________________________________________________________________________________

Previous ocular surgery:

Comments:

Signature:____________________________________