<Address Phone Email Website>
October 8, 2019 Tuesday, 08 October 2019 PATIENT DIAGNOSTIC REPORT FOR: PATIENT NAME Dear Dr <Surname>, My name is <Optometrist Name>, and I am the principal optometrist at <Practice Name>. This report is to provide you with information about your patient who has been attending <Practice Name>. I am available to discuss the patient with you or provide any further information should you require this. REASON FOR REPORT/REFERRAL: Enter comments DATE OF EXAM: Enter comments EXAMINATION TYPE: Enter comments EXAM RESULTS: Enter comments Visual Acuities: Enter comments Anterior eye exam: Enter comments Posterior eye exam: Enter comments Intraocular pressures: Enter comments Other tests: Enter comments DIAGNOSIS: Enter comments MANAGEMENT / RECOMMENDATIONS: Enter comments NEXT EXAM DUE: Enter comments OTHER NOTES: Enter comments
If you have any questions, please contact me on <phone number> at any time. Yours Sincerely, Optometrist Name & Qualifications