Referral for Consultation

Referral for Consultation
Thank you for choosing to refer your patient to Empire Eye and Laser Center. To start the referral process, please complete this form.
Referring Provider Information
Referring Provider Name*
Referring Provider Phone Number
Please enter a valid phone number.
Patient Information
Patient Name*

First NameLast Name
Patient Phone Number*
Please enter a valid phone number.
Patient Date Of Birth*

MonthDayYear
Date
Patient Insurance
Member ID
Consultation Request
Consulting Provider
Reason for Consultation*

Cataract EvalPlastic ConsultDry Eye EvalDiabetic EvalRefractive ConsultGlaucoma EvalAnnual Medical ExamPlaquenil EvalOther
Service Requested

Co-managementConsultation and Management2nd Opinion Only
Visual Acuity
OD 20/
OS 20/

Manifest Refraction
OD      = 20 /
OS      = 20 /
Additional Information
Attach File

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Referring Provider Information