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Home » Referral Request form – Dry eye treatment

Referral Request form – Dry eye treatment

Referral Request form - Dry eye treatment

  • The above mentioned patient has presented the following condition(s);

    • H40.013; Dry eye syndrome of bilateral lacrimal glands
    • H16.223; Keratoconjunctivitis sicca, not specified as Sjogren's, bilateral

    Requesting referral for additional testing due to medical findings that require further treatment. Below is a list of procedures that will need to be performed.

    • 68761 Punctal plugs
    • 83516 InflammaDry
    • 83861 TearLab Osmolarity Microfluidic Analysis Utilizing an Integrated
    • 65778 Prokera Graft