FORT LAUDERDALE EYE INSTITUTE
PHYSICIAN REFERRAL FORM
SELECT YOUR PREFERRED LOCATION IN THE DROPDOWN
*
Please Select
Plantation Office: 850 S Pine Island Road, Suite A100, Plantation, FL 33324
Fort Lauderdale Office: 1930 NE 47th Street, Suite 101, Fort Lauderdale, FL 33308
Our East Office is for Retina only patients
TODAY'S DATE
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Month
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Day
Year
Date
PATIENT NAME
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First Name
Middle Name
Last Name
Suffix
DATE OF BIRTH
*
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Month
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Day
Year
Date
PATIENT PHONE NUMBER
*
Format: (000) 000-0000.
PATIENT EMAIL ADDRESS
INSURANCE CARRIER
*
INSURANCE ID
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REFERRING PHYSICIAN OR PROVIDER NAME
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REFERRING PHYSICIAN OR PROVIDER PHONE
*
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Area Code
Phone Number
REFERRING PHYSICIAN EMAIL
example@example.com
REFERRING PHYSICIAN FAX #
Format: (000) 000-0000.
PLEASE CALL OUR OFFICE FOR SAME-DAY EMERGENCIES
Phone:
(954) 741-5555
HOW SOON DOES PATIENT NEED TO BE SEEN?
*
EMERGENCY
URGENT (within 1 WEEK)
ROUTINE
REASON FOR APPOINTMENT
*
minimum 5 words; maximum 250 - number typed =
0/250
WOULD YOU LIKE US TO CONTACT THE PATIENT FOR YOU?
*
YES
NO
WOULD YOU LIKE TO CO-MANAGE THE POST-OP CARE OF YOUR PATIENT AFTER CATARACT SURGERY?
Yes
No
PLEASE SELECT WHICH DOCTOR(S) YOU ARE REQUESTING AN APPOINTMENT WITH
*
PATIENT'S NOTES WILL BE PROVIDED WITHIN THREE WEEKS OF VISIT
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