Patient Referral Form

Thank you for visiting our Doctor's Portal. We appreciate your referrals and are here to assist you if you have any questions. You may also click here to directly email our team.

Referred Patient

First NameLast Name

Patient's Date of Birth

Date

Patient's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient's Email

example@example.com

What is the reason for the referral?

Referring Doctor Name:

Referring Practice Name:

Referring Practice Address:

Referring Practice Fax:

Referring Practice Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Refractive Error:
OD:
VA 20/
OS:
VA 20/

Eye Dominance:

Exam Findings:

OD:

OS:

If findings were Abnormal, please describe

Patient Interest:

Doctor's Recommendation/Comments:

Please upload any referral forms, exam history and patient demographics.

For assistance, please email our Clinic Director at nicolem@auroralasik.com or Dr. Angela Triebold at angelat@auroralasik.com.