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Physician Referral Form
Use this form to refer your patients to Richmond Eye Experts for Optometry or Optical Services.
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* Indicates required question
Referring Physician Name
*
Your answer
Referring Physician Phone Number
*
Your answer
Referring Physician Fax/HIPAA complaint email
Your answer
Date of Referral
Your answer
Patient Name
*
Your answer
Patient Date of Birth
Your answer
Patient Phone Number
*
Your answer
Patient Insurance Name and ID if available
Your answer
Reason for Referral
*
Diabetic Eye Exam
Pediatric Eye Exam - ages 4 and up
Glaucoma Evaluation
Hydroxychloroquine/ Plaquenil testing.
Ocular Surface Disease - Dry Eye Evaluation
Myopia Management Clinic - Orthokeratology
Myopia Management Clinic - Soft Dual Axis Lenses
Myopia Management Clinic - Atropine therapy
Specialty Contact Lens Exam - RGP/ Scleral Lens / Hybrid lens/ Custom soft lenses
Emergency - Pink Eye/ Red Eye/ Foreign Body removal
Optical Services
Contact Lens Services
Testing only - choose from option below
Required
Testing only - Test results will be sent back to the referring provider.
Retinal Imaging - Optomap
Visual Field Testing - Glaucoma
Visual Field Testing - Macula
Visual Field Testing - General
OCT - Anterior Seg
OCT - Macula
OCT - Nerve
Axial Length Measurement
Topography
Anterior Seg/ Slit Lamp Photography
Please add any other information you think maybe pertinent to the care of this patient. You may also fax your exam notes to 281-220-8522.
Your answer
Optometrists only: Would you like us to send this patient back to you for routine eye examinations?
Yes
No
Patient's choice
Clear selection
Thank you for trusting us with the care of your patient. We will contact the patient for continued care and keep you updated with the results of this referral.
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