Public Referral Form

Is this a new referral?

Yes

No

Email

Phone *

Fax *

Address

City *

State

Zip

Submitter's Name

First Name *

Last Name *

Date Of Birth *

Phone *

Email

Address

City *

State *

Zip *

Referring Doctor Patient Chart Number *

Interpreter Needed? *

Yes

No

Language

Email

Primary Insurance Provider

Insurance ID Number

Insurance Group Number

Secondary Insurance Provider

Secondary Insurance ID Number

Secondary Insurance Group Number

Consultation Type *

Cataract Consult RLE Consult ICL Consult PCO LASIK/PRK Consult

Notes to surgeon

File/Image Upload Medical Records are uploaded to a secure, HIPAA-compliant portal.

If surgery is recommended, I’d like to co-manage the patient’s post op care if the surgeon feels it is medically appropriate. If surgery is recommended, I’d prefer OVO LASIK and LENS to assume all of the patient’s post op care and will resume the general care of the patient after the post op period. I understand that all 1 day Post Ops will be seen by OVO LASIK + LENS, unless an additional agreement has been previously made

Email Fax

Referral Form

If this is an Urgent Referral please contact our office at (952) 204-5060