Diabetic Eye Exam Referral Form

Diabetic Eye Exam Referral Form — Form Fields

This healthcare template includes 12 fields. Primary care providers refer diabetic patients for annual dilated eye exams to screen for diabetic retinopathy. Free to customize and use on ZenBuild.

• Referring Provider Name (text, required)
• Provider Email (email, required)
• Patient Full Name (text, required)
• Date of Birth (text, required)
• Insurance and Member ID (text, required)
• Type of Diabetes (dropdown selection, required) — options: Type 1, Type 2, Gestational, LADA, Other
• Years with Diabetes Diagnosis (text, required)
• Most Recent HbA1c (%) (number, optional)
• Last Dilated Eye Exam (dropdown selection, required) — options: Within 1 Year, 1–2 Years Ago, More Than 2 Years Ago, Never
• Known Diabetic Retinopathy? (dropdown selection, required) — options: Yes - Non-Proliferative, Yes - Proliferative, No, Unknown
• Patient uses insulin (checkboxes, optional)
• Additional clinical notes (long text, optional)