Tpa Visit Patient Log
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1TPA VISIT
PATIENT LOG
Optometrist’s Name: __________________________________________________________________ License Number: ________________________________
Date
Patient ID Number
Glaucoma Comanagement
Referral Required
(yes/no)
(yes/no)
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GLOSSARY
Definition of TPA visit = A visit which involves ocular disease and a therapeutic pharmaceutical agent or procedure is
required. This includes visits which involves referrals for anti-virals, all glaucoma meds, steroids, or other procedures.
ID Number = Unique number to be assigned by optometrists. Cannot be a social security number.
Referral Required = Due to limited scope of licensure, a referral to an ophthalmologist is necessary.
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