Surgical Referral For Adults - Prevent Blindness Georgia

Here at PBGA, we help connect our clients to local eye health care professionals. Please fill out this form entirely to the best of your ability. We do require proof of income and a doctors note if you were not seen at a PBGA clinic.

Proof of income includes:

Last year’s W2
Last 2 months of bank statements = 1 proof of income
2 current paycheck stubs = 1 proof of income
Social Security Administration Award Letter.
Unemployment Claim/Wage Inquiry statement
ANY information regarding financial circumstances, including monthly amounts received on ANY other sources of income (ex: TANF, pension, retirement, child support, food stamps, part time employment, etc.)

Once we have received your completed form and documents, we will reach back out within 2 – 4 weeks.

Should you have any questions or issues when filling this form out, please email [email protected].

Surgical Referral Form

Name(Required)

Preferred Name

Date of Birth

Sex

Email Address

Address (City, State, Zip)

Cell Phone

Home Phone

Date of Last Exam

Please select which type of insurance you have

If you selected other for your insurance, please describe here.

What is the Total Yearly family income (i.e. ALL household income including spouse’s income, dependent income, etc.)?

Emergency Contact

Emergency Contact Phone Number

Name of responsible adult driving patient home from surgery

Height/Weight

Height (ft and in)

Weight (lbs)(Required)

Weight approximation within 10 lbs is acceptable, but answer is required!

Special Questions

Have you had a heart attack, stroke, or mini stroke (TIA) within the last 6 months ?

Do you have a pacemaker or implanted defribillator?

Do you use home oxygen?

If yes, please select:

Are you on dialysis?

If yes, please select

Dialysis Schedule

Dialysis Clinic and Location

Hospitalizations

Have you been hospitalized for any reason in the last six months?

If yes, list date(s) and reason(s):

Implants

Do you have implants or prostheses?

Type:

Women/Pregnancy

Please check if one of the following applies to you

Hysterectomy

Menopause

If not, are you currently or possibly preganant?

Yes

Date of last menstrual period

Cancer

Do you currently or have you ever had cancer?

Type & Date

Indicate any treatment you are currently undergoing:

Do you currently or have you ever had:

Angina, Chest pain or heart attack

Comments/Explanation

Heart surgery, stent, or ablation

Comments/Explanation

High or Low blood pressure

Comments/Explanation

Congestive heart failure

Comments/Explanation

Heart Valve disorder or murmur

Comments/Explanation

Irregular heart beat or arrhythmia

Comments/Explanation

Other (cardiovascular)

Comments/Explanation

Diabetes

Controlled by

Comments/Explanation

Asthma, restrictive airway, COPD, or other lung disease

Comments/Explanation

Tobacco use

Number of packs per day (if applicable)

Sleep apnea

If yes, do you use a CPAP or BiPAP machine?

History of or recent exposure to tuberculosis

Comments/Explanation

Hearing or Vision Impariment

Comments/Explanation

Mobility Restrictions

Able to stand/pivot?

Dentures, bridges, caps, crowns, chipped or loose teeth

Comments/Explanation

Current burns, rashes, bruises, or easy bruising

Comments/Explanation

Ulcers, hiatal hernia, or acid reflux disease

Comments/Explanation

Gallbladder condition or GI/rectal bleeding

Comments/Explanation

Depression, anxiety, panic disorder, or claustrophobia

Comments/Explanation

Seizure disorder, paralysis, or Parkinson's

Comments/Explanation

Alzheimer's or other dementia

Comments/Explanation

Stroke or mini Stroke

Comments/Explanation (date)

Neck, back or jaw problems or joint replacement

Comments/Explanation

Multiple sclerosis or muscular dystrophy

Comments/Explanation

Arthritis

Comments/Explanation

Is your neck movement significantly restricted?

If yes, explain

Are you able to lie flat?

If not, explain

Hypothyroidism or hyperthyroidism

Comment/ Explanation

Recent Blood transfusion or anemia

Comment/ Explanation

Bleeding or clotting disorder or history of blood clots

If yes, explain

Current use of blood thinners or Aspirin

Comment/ Explanation

HIV or other blood transmissible infection

Comment/ Explanation

Jaundice, cirrhosis, or hepatitis

If yes to hepatitis

Comment/ Explanation

Chronic kidney disease

If yes, what stage?

Kidney transplant or nephrectomy (removal of kidney)

Date

Alcohol use

Number of Drinks per day (if applicable)

Recreational Drug use

If yes, what:

Current Medications (please complete all fields)

Please list name of medication, dose, and how often you take it. Put N/A if not applicable.(Required)

Allergies/Intolerances (please include details of reaction)

Please list all of your allergies to medication and your reaction. Please put N/A if not applicable to you.(Required)

Surgical History

Please let all surgery procedures and their dates. Please put N/A if not applicable.

Anesthesia History

Have you or anyone in your family had an unusual reaction to anesthesia, such as

N/A

high temperature (malignant hyperthermia)

difficulty waking up

nausea/vomiting

If yes, please explain:

Providers/Specialists

IMPORTANT: Include full names of your primary care provider as well as any specialists (cardiologist, pulmonologist, neurologist, endocrinologist); Failure to do so may result in delay of your surgery.

Please list all providers - primary care providers and specialists (cardiologist, pulmologist, neurologist, endocrinologist) and their contact information.

Electronic Signature

Date (MM/DD/YYYY)

Financial Verification

Max. file size: 10 MB.

Please upload these forms to verify your proof of income.

Doctors Note

Max. file size: 10 MB.

If you were not seen at a PBGA clinic, please provide doctors note.

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