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403-696-1020
info@cloudbreak.ca
#215, 3917 University Ave NW Calgary AB T3B 6K3
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
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Referral Form
Referring Doctor Survey
Research
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About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
#215, 3917 University Ave NW Calgary AB T3B 6K3
#215, 3917 University Ave NW Calgary AB T3B 6K3
Southern Alberta
University District
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Menu
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Southwest Calgary
Suite 315, 5340 1 St SW Calgary, AB T2H 0C8
University District
Suite 215, 3917 University Ave NW Calgary AB T3B 6K3
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Menu
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Menu
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
403-696-1020
info@cloudbreak.ca
#215, 3917 University Ave NW Calgary AB T3B 6K3
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Menu
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Menu
About
Our Teams
Southwest Calgary Team
University District Team
Careers
Patients
Cataract
Glaucoma
Others
Prepare your First Visit
FAQ’s
Patient Form
Patient Survey
Referring Doctor
The Referral Process
Why Refer to Us?
Referral Form
Referring Doctor Survey
Research
Contact Us
Contact Southwest Calgary
Contact University District
Surveys
Referring Doctor Survey
Patient Survey
Blog
Referral Form
Select Clinic Location
*
Southwest Calgary
Suite 315, 5340 1 St SW Calgary, AB T2H 0C8
T: 403-281- 0603 / F: 403-281-2471
E: info@cloudbreak.ca
University District
Suite 215, 3917 University Ave NW Calgary AB T3B 6K3
T: 403-696-1020 / F: 403-640-4047
E: ud@cloudbreak.ca
Consult With
*
Next Available
Dr. Patrick Gooi (Glaucoma, Advanced Anterior Segment, Cataract)
Dr. Christopher Hanson (Comprehensive, Cataract)
Dr. Malcolm Gooi (Comprehensive)
Dr. Micah Luong (Comprehensive)
Dr. Delan Jinapriya
Dr. Helen Chung
Medical Urgency
*
Within a Week
Within a Month
Routine: Next Available
Urgent Glaucoma (please fax and phone)
Patient Information
First Name
*
Last Name
*
Date of Birth
*
Gender
*
Choose Gender
Male
Female
ACH#
Patient's Email Address
*
Address
*
Phone
*
Cell
Referring Clinic Information
Referring Doctor
*
Referring Clinic
*
Phone
Fax
Practice ID
Date
*
This referral for transfer of care
*
Yes
No
Co-Management of this patient is desired?
*
Yes
No
Conditions
*
Medical Glaucoma
Cataract
Comea
AMD (Wet/Dry)
Sudden Loss of Vision
Surgical Glaucoma
YAG Capsulotomy
Dry Eye
Diabetic Retinopathy
Pediatric
Narrow Angles / LPI
Dislocated IOL / Lens
Pterygium
Amblyopia
Uveitis
SLT / MLT
IOL Opacity / Dysphotopsia
Ptosis
Strabismus
Cyclophotocoagulation
Iris Defect
Thyroid Eye Disease
Plaquenil
Optic Nerve
Lipid Mass / Chalazion
Others
Appointment Policies and Reminders
*
Yes, I have read and understand these policies
Please allow yourself 1‐3 hours for each appointment Please provide at least 48 hours notice if you are unable to attend a scheduled appointment Missed appointments or late cancellations will be subject to a ‘No‐Show’ fee
VA
IOP
OD
*
OD
*
OS
*
OS
*
Additional Comments
*
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