Patient Referral Form
Thank you from all of us at Des Moines Eye Surgeons for your exceptional patient care. We look forward to working together! Please reach out to Meg at mropella@dmeyesurgeons.com if you need pamphlets, appt cards, post-op pads, etc.
Referring Provider Name
*
If you have multiple offices, which location? (City or street name is ok)
Referring Provider Phone #
Referring Provider Fax #
*
Patient Full Name
*
Patient Date of Birth
*
Patient Phone #
*
Patient Address (if not on visit notes)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Insurance Name/ID# (or attach card copy below)
*
**Our surgery center if out of network with Oscar MercyOne & MercyOne Medigold HMO (we are in network with the commercial version/non-MercyOne). We can see non-surgical consults for these insurances in our office.
URGENCY
*
EMERGENCY
Within the next 7-10 business days
Next available
Preferred Provider
David Ball, MD
Andrew Steffensmeier, MD
Matthew Raecker, MD
Frederick Blodi, DO
Matthew Meyer, MD
Kelly Baumhover, OD
Reason for Referral
*
Surgical Referral- Are you interested in comanaging this case if applicable?
*
Yes
No
Visit Notes / Insurance Card
*
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