Please complete/submit this form and fax doctor's notes and referral authorization if needed.
Urgent
Routine
Action Required
Call Patient to Schedule
Patient Name
First Name
Last Name
Date of Birth (DOB)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance
Patient Phone
-
Area Code
Phone Number
Patient Phone (Alternate)
-
Area Code
Phone Number
Referring Physician
First Name
Last Name
Referring Phone
-
Area Code
Phone Number
Referring Fax
Practice Name
Email
example@example.com
Reason for Consultation
CRVO, BRVO, CRAO, BRAO
Diabetic Retinopathy
Flashing Lights/Floaters
Hereditary Diseases/Genetic Consultation
Macular Hole
Macular Degeneration
Ocular Tumor
Retinal Detachment
Uveitis
The physician requesting this opinion understands that the consulting physician may initiate treatment or perform medically necessary diagnostics for this patient. The consulting physician will send the requesting physician an opinion and plan of care.
Additional Comments
Preferred Retina Physician
Alan J. Gordon, M.D.
J. Shepard Bryan, M.D.
Stephan A. Souza, M.D
Henry Mark Kwong, Jr., M.D.
Benjamin Bakal, M.D., P.H.D.
Jaime R. Gaitan, M.D.
Matthew Welch, M.D.
Rima Patel, M.D
Setu Patel, MD
Kunyong Xu, M.D.
1st Available
Preferred Location
Casa Grande
Cottonwood
Flagstaff
Gilbert
Goodyear
Mesa
Payson
Peoria
Phoenix
Prescott
Prescott Valley
Scottsdale
Sedona
Physician Referral Form
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