Provider Referral Form

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Submission of this form is secure and HIPPA-compliant.

Schedule your patient first. We STRONGLY recommend instantly scheduling your patient or have your patient schedule themselves at our scheduling page to secure the soonest available appointment slot, http://seesaweyes.janeapp.com/ . Thank you for your referral!

Our insurance and billing policies are available here:

https://seesaweyes.com/insurance

Complete the following form as best you can or fax us at 253-479-0104.

Patient Name *

Patient Date of Birth *

YYYY

Parent/Guardian Name (if under 18)

Best Phone Number (to reach patient or parent/guardian)

Type of Evaluation(s) Requested

Routine Eye Examination

Functional Vision Evaluation for Vision Therapy

Low Vision / Rehabilitation Evaluation

Infant or Toddler (5 and Under) Examination

Other:

Referral Date

YYYY

Clinical Concerns

Referring Provider

Provider Specialty

Provider Location/Clinic/School

If you would like to receive reports, please provide an e-mail, fax number, or mailing address:

How soon does this patient need to be seen?

< 1 week (please have patient contact our office)

< 1 month

Non-Urgent (~2 months)

Clear selection

For referring eye care professionals...

______________________________________________________________

(other professionals, submit form at the bottom)

Manifest Refraction OD

Manifest Refraction OS

Were glasses prescribed and dispensed?

Was a mydriatic/cycloplegic used?

Is the patient currently a contact lens wearer?

Any non-refractive ocular health diagnoses?

Additional Relevant Testing/Findings (or email to doc@seesaweyes.com or fax to 253-479-0104)

Submit

Again, we STRONGLY recommend having your patient schedule online at http://seesaweyes.janeapp.com/ so they are instantly booked and confirmed, or please contact our office if the patient needs to be seen urgently, as we do not have any availability for comprehensive examinations or evaluations sooner than our online scheduler shows. While we try to return referral requests as soon as we can, since we run the office on our own, this can take some time.

Thank you for your referral, please print this page for your records before hitting submit. Don't hesitate to reach out with any questions.

Submit

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