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ManualsBrandsWelch Allyn ManualsDiagnosticsTopcon TRC-NW400 Non-Mydriatic Retinal Camera

Welch Allyn VISION FOR ALL

Delivering simple and aordable screening solutions in primary care settings to help eradicate

some of the leading causes of preventable blindness.

Patient Information

Name:



Medical Record Number: 512124

Date of Birth: 8/14/1970

Referring Physician: 

Referring Clinic: 



™





Retinal Image Assessment and Management Plan

Fundus Photograph of Left Eye (OS): Fundus Photograph of Right Eye (OD):

Diagnosis for Left Eye (OS):

Diagnosis for Right Eye (OD):





ICD-10 Diagnosis Codes:





Recommendation and Management Plan:



Comments:

None







  654321

 

This report is provided by RetinaVue, P.C. through its licensed and board-certified ophthalmologists. The report specifies the presence of disease in the posterior pole of the retina for diagnostic, management and referral

purposes. It does not take place of a regular eye examination for the purpose of assessing the presence of glaucoma, cataract, anterior segment diseases, peripheral retina disease or other possible vision threatening

conditions. For customer support, please call 1.800.535.6663; 0 ption 2, 1, 3.

Diagnostic interpretation and electronic

report turned around in one business

day. Average time: 90 minutes

Diagnostic interpretation services are a

required component of the RetinaVue Network

and are contracted directly with RetinaVue P.C.

Referral/Screening plan clearly

details next steps

Comments, signature and license

number from board-certiﬁed

ophthalmologist

Diagnostic report includes retinal

images and contains all relevant

ICD codes

* RetinaVue Network software is shipped with either camera. System requirements: Windows 7, Windows 8.1, Windows 10 on latest SP; RAM 2 GB min; CPU

2 GHz or equivalent; 150 MB free HDD space; high speed internet connection; USB port (for RV100-B); Ethernet port (for 723427)

RV100-B*

RetinaVue 100 Imager

723427*

Topcon® TRC NW-400

Retinal Camera

723480

K2 Camera Table

723481

Lenovo® Thinkpad

Ordering Information

Welch Allyn, Inc.

4341 State Street Road

Skaneateles Falls, NY 13153 USA

(p) 800.535.6663 (f) 315.685.3361