External Referral Form

 (non-MCW physicians only)

To refer a patient to an AOIP imaging study complete the form and click submit. An AOIP staff member will receive the information and call the patient for scheduling.   Before completing, be sure to provide the prospective research subject with an overview of the AOIP Bank Study found here [PDF]Download the HIPAA document [PDF].  Submit the completed HIPAA document to AOIP via fax, (414) 955-6690, or upload through the form. Upon completion, you should see a Thank You message on the screen and receive an email confirmation of your form responses sent to the address listed in the physician email field. If you do not see the Thank You message or receive the email confirmation, please contact us at (414) 955-AOIP (2647) or email AOIP.

REFERRING PHYSICIAN INFORMATION Required fields *

Referring physician first name*

Referring physician last name*
Referring institution/clinic*
HIPAA form*
 Fax  Upload
Upload signed HIPAA document
Referring physician email*

This email address will be used for submission confirmation. 
Password*

If you do not have the password please call (414) 955-2647 (AOIP).
IRB PROTOCOL
 AOIP Bank
PATIENT BACKGROUND
Patient first name*
Patient last name*
Date of last eye exam
Patient phone number*
Patient email
If patient is a minor:
Gender*
 Male    Female
Patient date of birth*
Diagnosis/ocular history*
If other, enter diagnosis
Safe to dilate/adequate angle?*
Yes    No
Clear  +1NS  +2NS  +3NS 
Other
Yes   No
Yes   No
Refraction Data Available?
Yes    No
Refraction date done
Visual Acuity (corrected) OD
Prescription, OD
Visual Acuity (corrected) OS
Prescription, OS
IMAGING REQUEST
Eye(s) to be imaged*
OD   OS   OU
Describe region of interest.  Please also comment on the research question and previous/desired ancillary testing. 
GENETICS REQUEST
Has genetic analysis been done?*
Yes   No
If yes, briefly list results
Is genetic testing needed?*
Yes   No
Gene(s) of interest

Please click Submit below. You should see a Thank You message on the screen and receive an email confirmation of your form responses sent to the address listed in the physician email field above. If you do not see the Thank You message or receive the email confirmation, please contact (414) 955-AOIP (2647).

Advanced Ocular Imaging Program
Medical College of Wisconsin Eye Institute
925 North 87th Street
Milwaukee, WI 53226
Phone: 414-955-AOIP (2647)
Fax: 414-955-6690
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© 2017 Medical College of Wisconsin
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