Public Referral Form

Is this a new referral?

Yes

No

First Name *

Last Name *

Date Of Birth *

Phone *

Email

Type of Referral

Cataract

General

Glaucoma

Retina

Plastics

Check all that applies

Elevated IOP

Enlarged C/D

Narrow Angles

Ocular Hypertension

Surgical Evaluation

Comments Box

Choose one of the following:

If patient is stable OK to return to me for continued glaucoma monitoring.

Return to me for optical only, St. Luke’s to maintain glaucoma care.

Check all that applies

Comprehensive

Diagnostic testing

Diabetic Eye Exams

Dry Eye

Cornea

Comments Box

Check all that applies

Retinal Detachment

Retinal Tear/ Hole

Wet AMD

Dry AMD

Mac Hole

ERM

Nevus

Vein Occlusion

Diabetes with Severe Complications

Comments Box

Choose one of the following:

If the patient is stable OK to return to me for continued retina monitoring.

Return to me for optical only, St. Luke’s, to maintain retina care.

Please attach the last chart note, if available

Please attach any testing, if available

Ocular Medications

Dominant Eye

Diabetic

Yes

No

A1C

Mono CL Wearer: Distance Eye

Near Eye

Multifocal CL

Medications

Choose one of the following:

Elect co-management

Decline co-management

Patient`s Post-operative Vision Goals

I have reviewed lens options with patient including: Presbyopic IOL, Astigmatism Reduction (Toric IOL and/or LRI), Standard IOL (targeting distance or near vision), Monovision, etc.

My recommendation is Include any information that will help us match the lens choice with the patient’s uncorrected post-op vision goals

Recommended Target

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

Referring Doctor Comments

Insurance Carrier

Insurance ID Number

Insurance Group Number

Referral Form

If this is an Urgent Referral please contact our office at 727-943-3338