New Patient Referral

PATIENT REFERRAL
REFERRING PROVIDER INFORMATION
DATE

MonthDayYear
Referring Doctor Name*
Office Name
Office Phone Number*
Email*
Please enter the best email address for your office. If you do not have one please put info@info.com
PATIENT INFORMATION
Patient Name*
Date of Birth*

MonthDayYear
Patient Phone Number*
Patient Email
Primary Medical Insurance*
Medical Group (if applicable)
Authorization (please attach authorization)
*Sutter Requires Authorization from Sutter General Ophthalmologist
REFERRAL INFORMATION
Which Doctor are you referring to?*

Jacob Brubaker, MDSamuel Lee, MDXiongfei Liu, MDPatricia Sierra, MDPeter Wu, MDFirst Available GlaucomaFirst Available CorneaNo Preference
Preferred Office

SacramentoLincoln
Referral Urgency
Type of referral*

Cataract EvaluationCornea EvaluationGlaucoma EvaluationKeratoconus EvaluationLASIK/PRK/ICL - in Sacramento ONLYRefractive Lens ExchangeYAG Laser CapsulotomyOther
Previous LASIK/PRK

YesNo
Cornea Evaluation

Opinion on management ONLYOpinion on management and careAssume cornea careConsider Surgical Therapy
Glaucoma Evaluation

Opinion on management onlyOpinion on management and careAssume glaucoma careConsider surgical therapy
Co-Management Acknowledgement

Following our evaluation, we will communicate any findings and/or treatment recommendations.

If surgery is necessary please indicate below if you'd like to co-manage. Regardless, all patients will be sent back to the referring provider to resume general eye care as appropriate.
*

YES- If surgery is recommended, I’d like to co-manage the patient’s post op care if the surgeon feels medically appropriate.NO-If surgery is recommended, I’d prefer Sacramento Eye Consultants to assume the patient’s post op care and will resumethe general care of the patient after the post op period.
I accept the patient’s medical insurance:

YesNo
If recommended, I will co-manage MIGS:

YesNo
Additional Comments
Please attach most recent chart note(s), copy of insurance cards, demographics, images & test results.

HIPAA Compliant
Cancelof
Should be Empty:

PATIENT REFERRAL

REFERRING PROVIDER INFORMATION

PATIENT INFORMATION

REFERRAL INFORMATION