Referring Doctors

Specialty Contact Lenses

Medical Care

Thank you for allowing us to share in the care of your patients! In order to make their appointment proceed as smoothly as possible, please complete the referral form below and submit to us along with any supporting documentation and previous exam records. We will be happy to contact the patient directly to discuss the evaluation process or provide them with more details, as pertains to their unique needs.

Date(Required)

Referring Doctor

Name(Required)

OD / MD

Clinic Name(Required)

Phone(Required)

Fax(Required)

Patient Information

Name(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Insurance (Vision and Medical)

Referal Reason

Please select:(Required)

Scleral Lenses

Keratoconus Lenses

Myopia Control

Glaucoma Evaluation

Diabetic Eye Care

Plaquenil Treatment Monitoring

Other

Patient Care(Required)

I would like to refer this patient for complete transfer of care

I would like to continue comprehensive care, please co-manage medical conditions or contact lenses only.

Clinical Assessment/Diagnosis:(Required)

Exam notes / topography

Max. file size: 256 MB.

We will call your patient to schedule an appointment with one of our doctors within 2 business days of receiving this fax. You will receive a fax with progress notes on our evaluation and plan when your patient has been seen.

Referring Doctors

Referring Doctors

Specialty Contact Lenses

Medical Care

Referring Doctor

Patient Information

Referal Reason

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