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Patient Outcome Form
Patient Outcome Form
Doctor*
First Name
Last Name
Doctor's Email*
Doctor's Email
Patient*
First Name
Last Name
Patient's Email*
Patient's Email
Patient visit*
Patient was seen
Patient did not keep appointment
Patient did not schedule an appointment
Patient was not seen
Diagnosis (Check all that Apply)*
Amblyopia
Strabismus
Anisometropia
Chalazion
No Disease
Blocked tear duct
Refractive Error
Diabetic Retinopathy
Other:
Which treatment did you recommend? (Check all that apply)*
Surgery
Glasses
Other Amblyopia Treatment
Observation
Subspecialty Referral
Medication
Please circle the (closest) cost of care you provided for the initial ACS patient visit?*
$100
$150
$200
$250
$500
$1000
$1500
$2500
Please circle any subsequent costs you anticipate for the initial ACS patient visit. (e.g. surgeon's fees, ongoing care for one year within the program)*
$100
$150
$200
$250
$500
$1000
$1500
$2500
All Children See is not a program for people 18 and over.
Please, check our
other resources.
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