Refer A Patient

Name of Referring Doctor
Name*
Name of Clinic*
Phone*
Fax*
Email*
Patient
Heathcare Number*
Name*
First Last
Gender*
Birthdate*
MM slash DD slash YYYY
Address*
Street Address City Province Postal Code
Home Phone*
Referral Information
Billing Number*
Date of Last Exam*
MM slash DD slash YYYY
Medical Urgency*
- Routine: next available
- ASAP: within 24 hours
- Same Day / Urgent : within 12 hours
Reason for Referral
Reason for Referral*
Please Select Any Applicable*
- Ready for surgery
- Undecided
- Presbyopia treatment candidate
Additional Information
Eye Exam
Due to COVID-19 we ask that, if possible, you include a current photo of your patient’s eyes with every referral.
BCVA OD
BCVA OS
Refraction OD
Refraction OS
IOP OD
IOP OS
Patient's Eye*
Drop files here or

Max. file size: 256 MB.

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