Expedium Eye Questionnaire

WELCOME TO THE EXPEDIUM EYE ONLINE eADVICE AND REFERRAL PORTAL

IMPORTANT INFORMATION PLEASE READ BEFORE PROCEEDING

The Expedium Eye Clinic is dedicated to addressing your primary area of concern. Our goal is to provide an accurate diagnosis and recommend the most effective care pathway and any necessary referrals to manage your condition.

This registration and review process allows us to gather essential clinical information, helping to assess urgency, confirm a diagnosis, and determine the best treatment options for your patient.

Terms of Service

The Expedium Eye Assessment consists of a virtual consultation conducted by a Nurse Practitioner. The Nurse Practitioner will collaborate with an Ophthalmologist or other specialists to review the medical documents and questionnaire. The team will collaborate to develop personalized treatment recommendations and a management plan tailored to your patient.

The consultation, review, and management plan will center on the primary concern

THE NURSE PRACTITIONER WILL BE REVIEWING ALL PATIENT CARE PLANS WITH AN ORTHOPAEDIC SPECIALIST.

BASED ON THE REVIEW, YOU WILL BE PROVIDED WITH TAILORED TREATMENT RECOMMENDATIONS AND A MANAGEMENT PLAN. THE EXPEDIUM NURSE PRACTITIONERS WILL OVERSEE NON-SURGICAL CARE AND ONGOING MANAGEMENT.

PATIENTS DEEMED TO BE URGENT WILL HAVE AN EXPEDITED REFERRAL TO ONE OF THE EYE SURGEONS.

Terms of Service (Continued)

IF YOUR PATIENT IS REFERRED TO AN EYE SURGEON BY THE ASSESSMENT TEAM, PLEASE NOTE THE FOLLOWING:

THE AVERAGE WAIT TIME MAY BE 4-6 MONTHS FOR ROUTINE CONSULTATION WITH ONE OF THE EYE SURGEONS.

PATIENTS DEEMED TO BE URGENT, BY THE ASSESSMENT TEAM, WILL BE EXPEDITED TO ONE OF THE SURGEONS OR OTHER SPECIALISTS.

Wait times for specialist consultation and publically funded surgery in Alberta, are directly related to the available resources provided by Alberta Health Services.

Terms and Conditions

Once you submit your questionnaire, it will be automatically sent to the Expedium Eye Clinic for processing and review. One of the Expedium Nurse Practitioners will contact the patient within 4-5 business days of submitting the questionnaire.

IMAGING IS REQUIRED FOR CONSULTATION
- OCT of the concern
- Fundus photos of the concern
** If imaging is not sent; we are not able to consult and your referral will be declined**

THERE IS NO ASSESSMENT FEE

If your patient possesses a valid Alberta Health Number (PHN), their Provincial Health Plan covers the assessment, review and follow-up visits.

FOR MORE INFORMATION PLEASE VISIT

https://expediumeye.ca/
https://expediumeye.ca/consultation/

Terms and Conditions (Continued)

IF THERE IS A WCB CLAIM FOR THIS INJURY
- STOP: Patients with an active WCB Alberta claim for this injury should not proceed through this process. You may prefer your physician forward the referral directly to WCB Alberta.
OUT-OF-PROVINCE PATIENTS
- Non-Alberta residents may participate in a virtual assessment with the Expedium Orthopaedic Clinic, however, there will be a fee of $350.00 and they may not be able to access surgery in Alberta.
- Out-of-province patients may take the assessment report to their home province for surgical consideration if appropriate.

Privacy Policy

The privacy and security of our patients, and their information are the highest priority at Expedium Eye. Therefore, we do not save or store the content of this questionnaire. You will be required to complete the questionnaire in one sitting, you will not be able to SAVE and return to the questionnaire at a later time. If you do not complete and SUBMIT the questionnaire you will be required to re-enter the information if you choose to submit a referral/request in the future. Once you submit the questionnaire and complete registration, the document will be automatically sent to the Expedium Eye Care Coordinators.

Expedium Eye will never share your personal or health information with other individuals or organizations without your written or implied consent; including public organizations, corporations or individuals, except if the individual(s) or organization(s) are part of your care team or involved in the management and treatment of your condition(s). Expedium Eye does not sell, communicate, or divulge your information to any mailing list or service.

Acceptance

By clicking I Understand, you confirm that you have read all the information above including the terms and conditions herein, and you understand and agree to be bound by them.

NOW LET'S GET STARTED

Expedium Eye Assessment Questionnaire

* Mandatory Fields
Case #
Patient Information
First name*
Last name*
Date of birth*

MonthDayYear
Date
Gender*
Health Care Number (PHN)
Health card province issued
Cell or primary phone number*
Please enter a valid phone number.
Email
example@example.ca
Address
City
Province
Postal code
Height
if known
(Inches)
Weight in pounds
if known
BMI

BMI Reference Guide

Under 18.5: Underweight	18.5 - 24.9: Normal Weight	25 - 29.9: Overweight
30 - 34.9: Obese	35 - 39.9: Severely Obese	40 and over: Morbidly Obese

These are general references, always consider the patient's body type (morphology), which will impact their BMI score. For example; an individual with a muscular physique (mesomorph) may have a high BMI and not be considered obese.

Requesting/Referring Provider
Title
Requesting Provider's first name
Requesting Provider's last name
Clinic's name
Clinic fax number
Please enter a valid phone number.
Clinic phone number
Please enter a valid phone number.
Clinic address
Does the patient have a Primary Care Provider (PCP)/ Family Physician

YESNOUnknown
Primary Care Provider (PCP)/ Family Physician Information
I confirm that the patient does not currently have a family physician or primary care provider.
It is unclear whether the patient currently has a family physician or primary care provider.
Title
Family Physician's first name
Family Physician's last name
Clinic's name
Clinic phone number
Please enter a valid phone number.
Clinic fax number
Please enter a valid phone number.
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Terms and Conditions Agreement*

I agree to the Expedium Eye Clinic terms and conditions
I, {first_name} {last_name}, have read and agree to Expedium Orthopaedics' terms of service and privacy policy. I certify that the information I have provided is true and accurate to the best of my knowledge.

Information Sharing Agreement

I agree and consent to the sharing of this patient's personal and health information with other individuals or organizations who are part of my care team or who are involved in the management/treatment of the patient's condition(s), as outlined in the Health Information Act (HIA).

I agree and consent to receive secure electronic communications and understand that Caleo Health will send communications and notifications to the email address I have provided.

PLEASE NOTE:

Ensuring the privacy and security of our patient's information is Expedium Eye's top priority. Therefore, we do not retain or store the content of this questionnaire. You must complete the questionnaire in one session as there is no option to save and revisit it later. Failure to complete and submit the questionnaire will necessitate re-entering the information to submit a new referral/request. Upon submission, the completed questionnaire will be automatically forwarded to the Expedium Eye Care Coordinators.
eConsult Question
Please review the attached medical information and provide advice on the diagnosis, suitable care pathway options, and the appropriateness of a surgical consult.
Expedium Eye Referral Registration
Expedium Eye Referral Registration
icd_code
UUID
Date Questionnaire Submitted

MonthDayYear
Date
Should be Empty:

	Always	Almost Always	Almost Never	Never	N/A
Light sensitivity
Gritty feeling in your eye
Eye pain
Blurry vision
Poor vision

	Always	Almost Always	Almost Never	Never	N/A
Reading
Driving at night
Working with a computer or using a cash machine
Watching television

	Always	Almost Always	Almost Never	Never	N/A
Wind
Areas with low humidity (very dry)
Spaces with air conditioning

Expedium Eye Assessment Questionnaire

Patient Information

Requesting/Referring Provider

Primary Care Provider (PCP)/ Family Physician Information

Eye Diagram

Imaging Required for Consultation:

Social & Occupational History