The on-site diabetes teleophthalmology retinal screens will be available in VC220 for all AIM patients with
diabetes. Same day and pre-scheduled visits will be available.
In order to refer your patient for this service, print and complete referral sheet below
1) Circle one of the following:
“To Diabetes Retinal Photography in Room 220 – Today”
“To Diabetes Retinal Photography in Room 220 – Please schedule visit”
2) Please administer the following eye drops:
Proparacaine 0.5%: one drop to both eyes
Administered by _________________________________
Please administer the following:
Tropicamide 1%: one drop to both eyes (then repeat in 15 minutes if necessary)
Administered by __________________________________
Phenylepherine 2.5%: one drop to both eyes (then repeat in 15 minutes if necessary)
Administered by __________________________________
Proparacaine 0.5%: one drop to both eyes
Administered by _________________________________
MD Signature _________________________