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Reason For Appointment *

Central Serous Retinopathy
Complications of Cataract Surgery
Degenerative Myopia
Diabetes/Diabetic Retinopathy
Dry Macular Degeneration / Drusen
Endophthalmitis
Floaters and Flashes (PVD)
Histoplasmosis/Toxoplasmosis
Inherited Retinal Disorders
Lattice Degeneration
Macular Edema
Macular Hole
Macular Pucker (ERM)
Neovascularization
Nevus
Ocular Cancer / Melanoma
Other Retina or Vitreous Disorder
Retina Artery Occlusion
Retina Vein Occlusion
Retinal Tear
Retinal Toxicity
Retinopathy of Prematurity
Uveitis / Iritis
Wet Macular Degeneration
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Location of Diagnosis

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Additional Info

Visual Acuity

OD CC

OS CC

OD SC

OS SC

This condition has been present for approximately... *

Please see this patient within the next: *

Physician Requested *

Dr. Tosi

Dr. Shaw

Dr. Coussa

Any Doctor

Location Requested

Milwaukee (Mayfair)

Greenfield

Mequon

Waukesha

Kenosha

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MD/DO

OD

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