Refer A Patient

Please fill out the following fields. Your patient will be scheduled for an evaluation within 2 weeks.

For emergent cases, please call the Provider Line 443-632-2855 during business hours or the doctor on call 410-659-1044 after hours.

DO NOT USE FOR EMERGENCIES

This form is not to be used for emergencies, urgent request, or communication that require immediate attention. If there is a medical emergency, contact the doctor or practice directly, or dial 911.

Patient Name*

Patient's Phone*

Phone

Patient's Date of Birth*

Referring Doctor's Name (and location if you work at more than 1 location)*

Referring Doctor's Email Address*

Referring Doctor's Phone

Primary Reason for Referral*

Cataract Evaluation

LASIK Evaluation

Narrow Angle Glaucoma Evaluation

Open Angle Glaucoma Evaluation

Corneal Evaluation

Diabetic Evaluation

Diabetic Retinopathy

Flashes/Floaters

Blepharoplasty

Macular Degeneration

Strabismus/Amblyopia

Oculoplastics

Cosmetic

Other (please specify)

OS Refraction*

OD Refraction*

Other or Secondary Reason for Referral - please specify reason/s for referral in order of importance below

Referral to:

Select or enter value

Patient Insurance

If your patient has Jai Medical or Kaiser Medical Insurance, please have them contact their medical insurance. Patient will need to obtain a referral from Jai or Kaiser in order to see us otherwise, they will be considered self-pay and full payment is due at the time of the appointment.

File Attachments

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