This registration form must be completed and signed by the attending ophthalmologist for each visudyne treatment.
The collection of the information on this form is authorized by Clause 23(b) of O Reg 965, s.23, O. Reg 376/92, s.1. under the Public Hospitals Act R.S.O. 1980, Chapter 410 for the purpose of assessing monitoring patient use of verteporfin and payment therefore. For information about collection practices contact: INFOLINE TEL. 416 327-4327, Toll Free 1 800 387-5559, or TTY 1 800 268-1154.
White - Patient Canary - Hospital pharmacy Pink - Treating physician
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