WKI Ophthalmology Referral Form
For Physician/Clinic Use ONLY
Patient Info
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Insurance Policy
*
Policy Name
Policy Number
Patient Email
example@example.com
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the patient interested in a research study?
Yes
No
Unsure
Would you like to enter the patient's medical history?
*
Yes, via file upload
Yes, via copy/paste
No, I will send it via fax
Other
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Medical History
*If not submitted here, please fax the most recent exam notes and patient demographics face sheet
Referral Information
Referral to which Specialty?
*
Please Select
Retina
Glaucoma
Referring to:
Next Available Provider
Evan Berger, MD
Alan Wagner, MD FACS, FASRS, AME
Alaa Al-Dabbagh, MD
Kapil Kapoor, MD FACS, FASRS, AME
Referring to:
Next Available Provider
Harold Bernstein, MD, ABO, AGS
Diagnosis/Reason for Referral
*
Blurred Vision
Branch Retinal Vein Occlusion
Cataract
Central Retinal Vein Occlusion
Conjunctivitis
Corneal Abrasion or Ulcer
Diabetic Eye Exam
Diabetic Retinopathy
Dry Eye Syndrome
Epiretinal Membrane
Eye Cancer
Eye Flashes
Eye Injury
Floater
Glaucoma
Macular Degeneration
Macular Edema
Macular Hole
Oncology
Optic Neuritis
Retinal Detachment
Retinal Tear
Retinitis Pigmentosa
Uveitis
Other
Diagnosis/Reason for Referral
*
Blurred Vision
Cataract
Conjunctivitis
Eye Injury
Glaucoma
Optic Neuritis
Other
Is this patient being monitored for glaucoma?
Yes
No
Preferred Scheduling Time Frame
*
🚨 24 hours/Emergency (if emergency please call to expedite)
⚠️Urgent (24-48 hours)
📅 Routine/Non-Urgent
Other
Preferred Appointment Location
Please Select
First Available
Chesapeake
Churchland
Eastern Shore
Elizabeth City
Hampton
Kilmarnock
Norfolk
Suffolk
Virginia Beach
Referring Doctor Information
Name
*
Dr.
Nurse
PA
Prefix
First Name
Last Name
Provider/Practice Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Practice Fax Number
*
Please enter a valid phone number.
Specialty
Ophthalmology
Optometry
Endocrinology
Family Medicine
Oncology
Neurology
Rheumatology
Emergency Medicine
Other
Practice Name
Contact Name (if different)
First Name
Last Name
NPI Number
Practice Address
Street Address
Street Address Line 2
City
State / Province
City
Additional Information/Comments
Submit
Should be Empty: