Coastal Vision Medical Group E-Referral Form
Office Location
*
Any, first available
Chino
Irvine
Long Beach
New Port
Orange
Coastal Vision Representative (if known)
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Arlene Gutierrez
Gina Valdemar
Richard Valdemar
Pat Suarez
Other Consultation Type
First Name
*
Middle Initial
Last Name
*
Date Of Birth
*
Age
Gender
*
Male
Female
Phone Number
*
Email
*
Permission to text?
Type of Insurance (if known)
Street Address
*
City
*
State
*
Zip Code
*
UCVA OD 20/
UCVA OS 20/
Rx Stable Since
OD: MRx
BCVA
OS: MRx
BCVA
Rx Add
Monovision discussed
Dominant Eye
OD
OS
Target Rx OD
Target Rx OS
Contact Lens Wearer
Yes
No
Options Discussed (Check all that apply)
Toric IOL
Multifocal IOL
ORA
Femtosecond Laser
Appointment Pre-Booked Online?
Yes
No
Additional Notes / Comments
Attachments
Medical Records are uploaded to a secure, HIPAA-compliant portal.
City
Email Address
*
Phone Number
Fax Number
Co-Management Preferences
I will co-manage this patient's post-op care (including punctal plugs and dry eye management)
I am glaucoma certified and will manage the patient's glaucoma care
I am a Medicare provider and wish to participate in the 90-day post-op period following cataract surgery
Practice Name
*
Doctor’s Name
*
Consultation Type
*
Please Select Consultation Type
LASIK
PRK
ZEISS SMILE Pro
EVO ICL
Cataract
Custom Lens Replacement
Pterygium
Dry Eye
Glaucoma
iLink Corneal Cross-Linking (CXL)
Clinical Trial
Other
Select a Surgeon
*
Select a Surgeon
Submit
