www.oceyeinstitute.com - Referral Form

24422 Avenida De La Carlota, Suite 110
Laguna Hills, CA 92653
Tel (949) 770-1322 Fax (949) 770-0127
Referral To*

George M. Salib M.D (Eye Physician and Surgeon)
*

UrgentNext Available
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Today*

MonthDayYear
Date
Age - Days
Age*
Phone Number*
Email
example@example.com
MedicarePPOHMOOther
Indication for Consult
George M. Salib M.D*

CataractsGlaucomaDiabetesDry Eye/AllergiesMacular DegenerationPterygiumOther
MRX/Best Corrected Vision
UCVA
OD 20/
OD 20/
OD 20/
OD 20/
Contact Lens Wearer*

YesNo
For Cataract evaluation, the patient must be out of their Contacts for 3 weeks.
Previous Refractive Surgery

YesNo
Select One

MyopicHyperopic
Discussed Mono-vision

YesNo
Eye Dominance

ODOS
Comments
Surgery Options Discussed

FemtoMIGS Devices (I-stent/Omni)
IOL Options Discussed

Multifocal IOLToric IOLAccommodating/Extended Depth of focus IOL
Referring Doctor Information
Doctor’s Name*

First NameLast Name
Date of Referral*

MonthDayYear
Date
Phone*
Fax
Email
example@example.com
Please refer the patient back to me for post-operative care and co-management purposes.Please provide all post-operative patient care. I do not wish to participate in co-management. Refer the patient back to our office for ongoing care.
Doctor’s Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Indication for Consult