OD Referral Form
Referring Doctor Information
Practice Name
Dr. Name:
First Name
Last Name
Doctor's Email
*
example@example.com
Reason For Referral
Please Select
Cataract Eval
YAG Eval
Dry Eye Eval
Glaucoma Eval
Red Eye
Painful Eye
Loss of Vision
Corneal Eval
Injury
Retina Eval
Strabismus/Diplopia Eval
Disc Eval
Special Testing (OCT,VF, Other)
SLT
Durysta Implant
Other (Please Provide Comments below)
Other reasons/comments
Patient Information
Patient Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Patient Phone Number
Please enter a valid phone number.
Patient Email
example@example.com
Insurance Carrier
Insurance Policy Number
Urgency of Referral
Please Select
Urgent, within 24 hours
Within 48 hours
Within 1 week
Not Urgent
Best Corrected Visual Acuity
OD BCVA
Please Select
20/10
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
CF
HM
LP
NLP
OS BCVA
Please Select
20/10
20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/200
20/400
CF
HM
LP
NLP
OD Manifest for BCVA
OS Manifest for BCVA
Fill in the following if the patient has already been scheduled for an appointment
Appointment Date
-
Month
-
Day
Year
Date
Appointment Time
File Upload
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Please fax/attach your latest exam including most recent refraction and BCVA
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