Refer a Patient
Thank you for your referral! This form submission is encrypted and HIPAA compliant for the transfer of patient information.
Referral Information
Patient Name
*
First Name
Last Name
Patient Phone Number
*
We will call the patient to set up their appointment.
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Pt for:
*
Glaucoma Eval
Cornea Eval
Cataract Eval
Diabetic Eye Exam
Specialty Contact Lens
Comprehensive Eye Exam
Pediatric Exam
Other
Appointment Urgency
*
Please Select
Standard Referral - Provider Availability
Urgent - Next Available Appointment
Very Urgent - Work in within the next 48hr
If this is a medical emergency please call 9-1-1.
Who would you like to refer this patient to?
Sarah Berry, OD
Waid Blackstone, MD
Jeff Chaiprakob, MD
Priscilla Fowler, MD
Hogan Knox, MD
Frank LaRussa, OD
Virginia Lolley, MD
Andrew Mays, MD
Blythe Monheit, MD
Jim Rains, MD
Lindsay Rhodes, MD
Carol Rosenstiel, OD
Isabella Simmons, OD
Carrie Smith, OD
Jason Swanner, MD
Kayla Thomason, OD
Any Comprehensive Eye Care Provider
Any Glaucoma Provider
Any Cornea Provider
Any Cataract Surgeon
Other
Patient Insurance Name:
Policy Info:
Use the field below to provide comments about diagnosis & treatment so far. (optional)
Please upload your previous chart notes and other patient files here:
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Referring Provider Information
Referring Provider Name:
*
Referring Provider Fax:
We will use this number to fax notes back.
Referring Provider Email
We will send a confirmation to this email when your referral is received.
Is this a co-managed surgery?
Yes, send me a comanagement form.
No.
Other
Is your practice on Nextech?
Yes, add me to Nextech Shared Care.
Yes, but please still fax me notes.
No.
Other
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