New Patient Referral

PATIENT REFERRAL
REFERRING PROVIDER INFORMATION
DATE

Month Day Year
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

Month Day Year
Patient Phone Number
Patient Email
Primary Medical Insurance
Medical Group (if applicable)
Authorization (please attach authorization)
REFERRAL INFORMATION
Which Doctor are you referring to?

Jacob Brubaker, MD Samuel Lee, MD Xiongfei Liu, MD Patricia Sierra, MD First Available Glaucoma First Available Cornea No Preference
Preferred Office

Sacramento Lincoln
Referral Urgency
Type of referral

Cataract Evaluation Cornea Evaluation Glaucoma Evaluation Keratoconus Evaluation LASIK/PRK or Refractive Lens Exchange Evaluation Refractive Lens Exchange YAG Laser Capsulotomy Other
Previous LASIK/PRK

Yes No
Cornea Evaluation

Opinion on management ONLY Opinion on management and care Assume cornea care Consider Surgical Therapy
Glaucoma Evaluation

Opinion on management only Opinion on management and care Assume glaucoma care Consider 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.
*

If surgery is recommended, I’d like to co-manage the patient’s post op care if the surgeon feels medically appropriate. 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:

Yes No
Additional Comments
Please attach most recent chart note(s), images & test results

HIPAA Compliant
Cancel of
Should be Empty:

PATIENT REFERRAL

REFERRING PROVIDER INFORMATION

PATIENT INFORMATION

REFERRAL INFORMATION