Skip to content
Facebook
Twitter
Instagram
Search for:
DONATE
DONATE
Outcome
admin
2023-07-26T15:27:59-05:00
Outcome
Doctor
(Required)
First
Last
Doctor's Email
(Required)
Patient
(Required)
First
Last
Type of Visit
(Required)
Initial Visit
Follow Up Visit
Patient Visit
(Required)
Patient was seen
Patient did not keep appointment
Patient did not schedule an appointment
Diagnosis (Check all that Apply)
(Required)
Amblyopia
Amblyopia suspect
Anisometropia
Blocked tear duct
Chalazion
No Disease
Refractive Error
Strabismus
None
Other:
Which treatment did you recommend (Check all that Apply)
(Required)
Surgery
Glasses
Other Amblyopia Treatment
Observation
Subspecialty Referral
Medication
Eye Patching
None
Please indicate the estimated cost of care you provided for the ACS patient visit.
(Required)
$0
$100
$150
$200
$250
$500
$1,000
$2,000
Please indicate any subsequent costs you anticipate for the ACS patient visit. (e.g. surgeon's fees, ongoing care for one year within the program).
(Required)
$0
$100
$150
$200
$250
$500
$1,000
$2,000
$2,500
$5,000
Glasses
Eye Patching As Needed
Hidden
Please indicate any subsequent costs you anticipate for the ACS patient visit. (e.g. surgeon's fees, ongoing care for one year within the program).
(Required)
$0
$100
$150
$200
$250
$500
$1,000
$2,000
$2,500
$5,000
Glasses
Eye Patching As Needed
Page load link
Go to Top