TO REQUEST AN APPOINTMENT: Fax (or email) completed form to: Mélanie R. Lalonde, PhD, CCRP, Vision Research Manager Fax: 613-739-6970 | SHORT NAME: DEPARTMENT: CONTACT PERSON: PI: Tel: (if different from PI): REFERRING INVESTIGATOR E-mail: OPHTHALMOLOGY ASSESSMENTS AND/OR RESEARCH DIAGNOSTIC TESTS: Tech work-up (incl. PoHx, Ocular Meds, C/c, Allergies, ACD by VH, Dilation if applicable) Ophthalmology Assessment (Slit-lamp Exam / Funduscopy); Dr. (specify if applicable): Aberrometry Injections E.g. Intravitreal Specular Microscopy – Annidis RHA Low Contrast Sloan Tear Film Break Up Time (TBUT) – – Amsler Grid Low Contrast TearLab – Axial Biometry MMP-9 Tonometry IOP – Contact B-Scan OCT Cirrus Ultrasound Biomicroscopy (UBM) – Color Vision OCT Spectralis Visual Acuity Distance ETDRS – – Electro-oculogram (EOG) Pachymetry Visual Acuity Distance Snellen – Electroretinogram (ffERG) Photography External Eye Visual Acuity Near Vision – – ERG Multifocal (mfERG) Photography Fundus Visual Evoked Potential (VEP) – – ERG Pattern (PERG) Photography Slit-lamp Visual Field (VF) Confrontational – – – Fluorescein Angiography (FA) Refraction Visual Field (VF) Goldmann – Fundus Autofluorescence RPS AdenoPlus Visual Field (VF) Humphrey – Heidelberg Retinal Tomography Schirmer’s Tear Test Other (specify): (HRT3) Circle: with or without anaesthesia SPECIAL INSTRUCTIONS: Research Participant ID: Visit #: Please specify visit window, preferred date/time for the appointment and dates when not available: OFFICE USE: Date: Time:
TO REQUEST AN APPOINTMENT: Fax (or email) completed form to: Mélanie R. Lalonde, PhD, CCRP, Vision Research Manager Fax: 613-739-6970 | SHORT NAME: DEPARTMENT: CONTACT PERSON: Tel: E-mail: PI: REFERRING INVESTIGATOR (if different from PI): OPHTHALMOLOGY ASSESSMENTS AND/OR RESEARCH DIAGNOSTIC TESTS: Tech work-up (incl. PoHx, Ocular Meds, C/c, Allergies, ACD by VH, Dilation if applicable) Ophthalmology Assessment (Slit-lamp Exam / Funduscopy); Dr. (specify if applicable): Aberrometry Injections – E.g. Intravitreal Specular Microscopy Annidis – RHA Low Contrast – Sloan Tear Film Break Up Time (TBUT) Amsler Grid Low Contrast – TearLab Axial Biometry MMP-9 Tonometry – IOP Contact B-Scan OCT – Cirrus Ultrasound Biomicroscopy (UBM) Color Vision OCT – Spectralis Visual Acuity – Distance ETDRS Electro-oculogram (EOG) Pachymetry Visual Acuity – Distance Snellen Electroretinogram (ffERG) Photography – External Eye Visual Acuity – Near Vision ERG – Multifocal (mfERG) Photography – Fundus Visual Evoked Potential (VEP) ERG – Pattern (PERG) Photography – Slit-lamp Visual Field (VF) – Confrontational Fluorescein Angiography (FA) Refraction Visual Field (VF) – Goldmann Fundus Autofluorescence RPS AdenoPlus Visual Field (VF) – Humphrey Heidelberg Retinal Tomography (HRT3) Schirmer’s Tear Test Circle: with or without anaesthesia Other (specify): SPECIAL INSTRUCTIONS: Research Participant ID: Visit #: Please specify visit window, preferred date/time for the appointment and dates when not available: OFFICE USE: Date: Time:
OPHTHALMOLOGY%20RESEARCH%20REQUISITION%20version%2020180417-MRL%20clean.docx