Generate Retina IQ Report

Populate report fields

Report Date

Scan / Image Date

Patient First Name / Initials

Patient Last Name / Initials

Date of Birth

Clinic Patient ID / MRN

De-identified Clinic / Patient ID for Invoice

Request ID / Tracking

Billable Images Reviewed

Provider/site autofill: Select the requesting OD/site to populate report recipient and monthly invoice filters.

Site / Eyecare Professional

Site ID

Eyecare Professional / Practice

Site Invoice Email / Recipient Contact

Pertinent Medical History

Pertinent Ocular History

Clinical Question / Reason for Request

Interpreting Physician First Name

Interpreting Physician Last Name / Credentials

Interpreter Credentials

Image Quality

Modalities Reviewed

Right Eye (OD)

OD Fundus Finding 1

OD Other / Free Text 1

OD Finding 2

OD Other / Free Text 2

OD Finding 3

OD Other / Free Text 3

OD OCT Finding 4

OD Other / Free Text 4

Left Eye (OS)

OS Fundus Finding 1

OS Other / Free Text 1

OS Finding 2

OS Other / Free Text 2

OS Finding 3

OS Other / Free Text 3

OS OCT Finding 4

OS Other / Free Text 4

Impression

Impression 1

Impression 2

Impression 3

Impression 4

Recommendations

Recommendation 1

Recommendation 1 Notes

Recommendation 2

Recommendation 2 Notes

Recommendation 3

Recommendation 3 Notes

Recommendation 4

Recommendation 4 Notes

Electronic Signature

Interpreter Typed / Electronic Signature

Signature Date/Time

I agree that my typed/electronic signature is legally effective for this Retina IQ analysis report.

Request Retina IQBack to Admin

Report generated and logged locally for monthly invoicing. Use your browser print dialog to save as PDF or print.

Report preview

The generated report opens as a separate print-ready consultation letter. Update the preview before generating if you want to confirm the content.