Refer a Patient — Smart Eye Care
Thank you for referring your patient to Smart Eye Care. Fields marked with a red asterisk are required. Everything else is optional — send what you have and we'll follow up promptly. All information transmitted securely.
Referring Provider
Provider Name
*
Practice or Clinic Name
Specialty
Provider Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Fax
Provider Email
example@example.com
Patient Information
Patient Full Name
*
First Name
Last Name
Patient Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Language
Insurance Carrier
Member ID
Has the patient been notified of the referral?
Yes — patient is expecting your call
Yes — but the patient will reach out on their own
No — please introduce yourselves
Reason for Referral
Condition / Suspected Diagnosis
*
Preferred Location
Please Select
No preference
Brooklyn Heights — 142 Joralemon St
Sheepshead Bay — 2613 E 16th St
Bronx — 665 Pelham Parkway North
Clinical Notes / Relevant History
Attach Records (PDF, JPG, PNG)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
By submitting, you confirm you have the authority to share this patient's information for the purpose of coordinating care. Smart Eye Care adheres to HIPAA and all applicable privacy regulations.
Submit Referral
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